Guest column: Obama’s Affordable Care Act is bad medicine for America

“As a father of two healthy kids who spent $17,000 last year on COBRA premiums in the good old ‘unregulated’ state of Texas, I welcome any attempt the Affordable Care Act makes at cost reduction. Heck, even the fiscal conservative Mitt Romney was behind Massachusetts’ health care reform, so I have to believe his intent was the same (perhaps I’m horribly naive.) we clearly need to do something, and if the ACA doesn’t work out we need to try again until we get it right. I didn’t see you offer any alternatives, making me wonder if you think the status quo is fine. if so, see my first sentence.” – Greg M

“we need a real ‘Single Payer Health Plan’ like what was originally asked for by the Obama administration. I’m so tired of healthcare being a haven for rich kids seeking careers. Do you remember a time when physicians practiced healing because they really cared about people and science? The change will be refreshing to see Docs beaten like teachers into submission by the media. Get the money out of healthcare and the true healers will come. at least that’s what they tell me about education?” – newsboy

The PPO insurance makes use of the health care networks and also provides flexibility to the customers to take a break from the network service providers, in case they are willing to get better services at increased costs. The PPO plans are normally scaled between the very restraining but very less pricey Health Maintenance Organizations (HMOs), and the service plans, having no restrictions but higher amount of premiums. Further in this article, I have discussed some basic terms related with the PPO health cover plans. You are required to go through the below mentioned points carefully in order to know more about these PPO health cover plans.

1. Co-Payments
The HMO’s required all the clients to remain within the network. However, on the other hand, a PPO customer can choose to avail the services of a physician even from outside the network. in this case, the customer has to pay higher amount of co-payment cost in comparison to availing within the network services. Co-payment is considered to be a specified amount of flat fee which is required for a particular service.

2. Co-Insurance
The co-insurance costs are also more, in case the customers visit any physician outside the network. The insured person is entitled to pay a certain percentage of the cost of all the covered services. The percentage is near about 10% if availing the services from within the network, and 30% in case third party physicians are consulted.

3. Deductibles
In case of the HMOs, there was no such term like deductibles. but in the case of PPO, if you are availing the services of a physician outside the network, you are required to pay higher amount of deductible. This amount of deductible has to be paid well before the insurance company starts dealing with your expenses.

4. Specialists
In case of HMOs, the customers were required to see the primary doctor in order to get a referral to a particular specialist. but, the case is different with the PPOs. in case of the PPO, health plans permit the customers to directly visit a specialist without getting a referral.

5. Availability
A large number of employers as well as the direct purchase insurance service providers offer both the HMO as well as PPO options. An individual can make sure that, whether the additional health care expenses associated with the PPO health care plans are worth every penny.

So, these were some main terms associated with the PPO health insurance plans. Make sure you go through the above mentioned points carefully in order to know more about the PPO health cover plans.

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The Bank’s Monetary Policy Committee (MPC) is forecast to increase its quantitative easing (QE) programme by

Because making a claim seems to be a lose-lose situation; just because you are telling the truth and playing by the rules, doesn’t mean they are, and if there’s a tiny, hidden loophole they can use to get out of paying you, it seems they will.

Insurers have been getting away with it for years, happy to take our monthly payments but not so happy to ever give any of it back. I didn’t think they could sink any lower in my estimation but apparently the feeling’s mutual.

Insurance companies now think so little of the moral fibre of their customers that when someone makes a claim they are henceforth considered uninsurable and forced to resort to specialist insurers – at an even more sky-high premium than they were paying before.

So exactly what do we pay our premiums for, if not to cover ourselves should the unthinkable (and expensive) happen? We’ll soon be buying insurance to cover the insurance not paying out!

I’m still trying to rub the pain of my holiday insurance away but with a final fee amounting to over half the cost of the entire holiday. It’s a sore point that will need rubbing for some time. And never mind high days and holidays . . . for those suffering illness, disability or pensioners, every day is an insurance nightmare.

Everyday activities become an opportunity for insurers to demand fees hugely disproportionate to the risk involved. And an opportunity to wriggle out of any claims that may arise, based on that old chestnut, “undisclosed information”.

The thing is, for anyone with health problems, there will always be some small, barely relevant morsel of medical history, burrowed down deep in hospital files, just waiting to be seized upon as a reason not to pay out on your claim.

But I’m not one to hold a grudge. A couple of years ago I experienced the rare joy of a successful claim. I had an accident while holidaying in Egypt and needed hospital inpatient care, surgery and repatriation using the Egyptian Air Ambulance – a costly exercise to say the least.

Try though they might to wriggle out of responsibility, in the end my total and utter honesty when taking out the policy won the day and my insurers copped for the lot. Surely satisfying enough, but get this – for some bizarre and still unclear reason, my travel insurance that year was unbelievably cheap.

Instead of the usual £400 or £500 premium, it was precisely £22. I questioned it at the time, but they assured me I was indeed covered. A promise I kind of think they lived to regret.

I’m not vindictive but it’s nice to know there’s still some justice in the world.

Plus, how to avoid common pitfalls when buying insurance on your own

YONKERS, N.Y., Feb. 7, 2012 /PRNewswire-USNewswire/ — Brand name insurance companies are selling health coverage as skimpy as a hospital gown.  The leading example of so called “junk health plans,” cited in a new report in the March issue of Consumer Reports, are mini-meds, which the magazine describes as “legal but inadequate.” Other misleading products include fixed benefit indemnity plans and medical discount cards.  The report is available online at ConsumerReports.org.

Because the federal government has granted waivers—a total of 1,231 covering 3.9 million people as of January 2012—to several large, well-known companies, mini-med junk plans continue to operate, and disappoint, even though they represent the type of misleading and extremely limited health coverage that the Affordable Care Act was designed to eliminate.  The waivers will expire in 2014 when health reform goes fully into effect.

“Mini-meds appeal to large employers in industries such as retail, food service, and temporary staffing agencies who want to be able to tell their employees ‘I have something for you.’ but in reality, these plans are extremely limited in their coverage.  The problem is that many consumers don’t know how to judge the merits of a health plan so they get sucked in,” says Nancy Metcalf, senior program editor, Consumer Reports, and the author of CR’s “Ask Nancy” Blog on health insurance. “But if they have a catastrophic illness or accident, they’ll quickly realize their coverage is hopelessly inadequate.” 

Fifty health insurance companies have federal waivers to offer “mini-med” policies until 2014.   these well-known brands have the highest enrollment:  Cigna Starbridge (265,000 enrollees), Aetna SRC (209,423), BCS Insurance (115,000) including McDonald’s hourly employees, and American Heritage Life Insurance co. (Allstate; 69,945).          

Surveys by Consumer Reports have identified health care costs as one of the most burdensome financial woes for consumers.  “Consumers don’t realize that a bargain on health insurance isn’t like a bargain on a flat-screen TV.  With health insurance, you truly get what you pay for,” says Metcalf.  “If what you’re being offered is dirt-cheap, then it’s probably not going to give you meaningful coverage.” 

Other misleading products include fixed benefit indemnity plans and medical discount cards, which are aimed at people who don’t have employer group  insurance,  not  even  a  mini-med.  If  you’ve ever received a fax or robo-call or seen a late-night TV ad offering affordable health insurance, it was most likely for one of these products.  And they are all over the Internet, ready to ensnare unsuspecting consumers who type “affordable health insurance” into their favorite search engine. although often marketed as if they were real health insurance, they are not.

Fixed benefit indemnity plans will reimburse a set sum, generally low, for medical services, after which a consumer is on his or her own, most likely with a lot of medical debt.  The medical discount cards promise discounts on services and other products in exchange for a monthly fee.  “As with mini-meds, these products could leave you on the hook for tens of thousands of dollars of medical debt if you should ever become seriously ill,” says Metcalf.  

The report, available online at ConsumerReports.org, details eight signs a plan might be junk, plus these tips for avoiding pitfalls when buying insurance on your own: 

• Don’t shop from a search engine. “If you Google ‘affordable health insurance,’ you will see sites that promise instant quotes.  you should avoid this option at all costs,” says Metcalf.  Brand-name major medical insurers rarely market to consumers in a direct-to-consumer fashion and it’s hard to tell who is legit.  Instead, consult a reputable independent health insurance broker who handles products from multiple companies.
• Don’t respond to flyers on telephone poles, faxes, robo-calls, or late-night infomercials.
• Look up real plans at Healthcare.gov.  on this federal web site consumers can search for all legitimate licensed health plans sold to individuals in their given state.
• Check with your state insurance department.  Consumers who submit questions to Consumer Reports’ “Ask Nancy” blog are rarely aware that health plans sold to individuals are regulated by the states.  most state insurance department websites have a guide that explains which major medical plans are licensed by the state.
• Make sure everything is covered.  Until health reform goes fully into effect in 2014, insurers can sell plans that don’t cover some basic medical services. many plans don’t cover prescription drugs, or cover only generics. Some plans in New Jersey cover only $500 a year in outpatient diagnostic tests and don’t cover drugs or cancer chemotherapy. Avoid these types of plans. even if you don’t need costly services now, you could down the road. 
• Find out whether your group plan is a mini-med. The government requires all mini-meds with waivers to include a disclaimer that reads something like this one on a Cigna plan: “Your health coverage…does not meet the minimum standards required by the Affordable Care Act.”   a disclaimer such as this one is a major red flag, says Metcalf.
• Know your COBRA rights.  if you leave your job and your workplace has 20 or more employees, the federal COBRA law entitles you and your dependents to stay on your group plan for up to 18 months so long as you pay the full premium yourself, which can be costly.  to learn more about COBRA, go to the Department of Labor’s website at dol.gov. 
• Consider Pre-existing Condition Insurance Plans.  if you have a serious pre-existing condition and can’t find a carrier who will insure you, you are eligible for coverage under the Pre-existing Condition Insurance Plan created by the health reform law. 
• Investigate public programs.  if your income is on the low side, your children may be eligible for free or low-cost insurance through your state’s CHIP program, and depending on your state’s eligibility rules, you may be able to get on Medicaid.

Consumer Reports is the world’s largest independent product-testing organization. Using its more than 50 labs, auto test center, and survey research center, the nonprofit rates thousands of products and  services annually. Founded in 1936, Consumer Reports has over 8 million subscribers to its magazine, website and other publications.  its advocacy division, Consumers Union, works for health reform, product safety, financial reform, and other consumer issues in Washington, D.C., the states, and in the marketplace.

MARCH 2012The material above is intended for legitimate news entities only; it may not be used for advertising or promotional purposes. Consumer Reports® is an expert, independent nonprofit organization whose mission is to work for a fair, just, and safe marketplace for all consumers and to empower consumers to protect themselves.  We accept no advertising and pay for all the products we test. We are not beholden to any commercial interest. Our income is derived from the sale of Consumer Reports®, ConsumerReports.org® and our other publications and information products, services, fees, and noncommercial contributions and grants. Our Ratings and reports are intended solely for the use of our readers. neither the Ratings nor the reports may be used in advertising or for any other commercial purpose without our permission. Consumer Reports will take all steps open to it to prevent commercial use of its materials, its name, or the name of Consumer Reports®.

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In the 1 Care Health Reform plan, there are four proposed phases of transformation that could take anything from 10 to 15 years (according to officials), depending on the uptake of the various phases and programmes, as well as its implementation progress.

Importantly, the Health Ministry increasingly understands that it would require general public acceptance, as well as significant consensus and (if possible) seamless buy-in from as many stakeholders as possible.

There is recognition that if the public fails to accept this in toto or in part, then there might be need to re-tweak or re-design certain aspects of the reform plans. Just how much the bureaucrats or our political masters are willing to change and adapt remains to be seen.

Therefore, it is crucial, indeed essential, that the public and interested stakeholders take an active role in providing enough input to help make this reform the one that they want. we should not simply accept a top-down programme designed by bureaucrats, and selectively enacted by policy makers. why? because, it would be disastrous if this reform fails or runs into the usual gaffes, just a few years down the line. Health care is simply too unforgiving and vital to fail or be subject to arbitrary social experimentation, no matter how good the intentions!

The current reform of the British National Health Service has almost run aground on several gridlocks and are now almost back to where it began just a year or so ago, after it was forcibly implemented against the bulwark of criticisms from several professional bodies, including doctors groups, healthcare workers and even business concerns. Chapter 17 discusses this debate in greater detail.

In the 1990s, Hilary Clinton and Newt Gingrich tried as a bipartisan Congress-Senate committee to radically reform the US health system, and this was totally rejected despite a six-year effort of intense debates and consultations. Even the Obamacare health reform was passed after severe truncations and whittling down of its programs and reach. there are still challenges, which remain to thwart its full if stuttering implementation.

Thus, reforming something so fundamental as healthcare is not something that any government can simply impose without feeling the pulse of civilian or partisan backlash, unless this can be made as consensually acceptable as possible, with as little disruptions or perceived inequities as possible.

Clearly, too, any reform or change will not be able to win over everyone or every dissenter. But at least, the majority must be able to accept, to believe in and buy into the system so transformed.

Two-way public consultations are crucial

So what about our own proposed health reform? Have there been enough high-level consultations and public input? there have been consultative meetings through various technical working groups (TWGs) involving an array of invited stakeholders, including the MMA, GPs, universities, private hospital and insurance groups, economic panning unit officials, etc.

However, the input into these TWGs appears fragmented and somewhat tailored to narrowly focused policy-directed micro-minutiae goals — the consultative groups are supposed to simply address the practical implications where they could be foreseen according to such objectives. By the way, almost all the TWG participants have to sign, under the Official Secrets Act (OSA), not to divulge these secrets on pain of prosecution!

The question, then, is if this sort of consultation reciprocal and two-way, or are they simply top-down exercises to assuage the “need” for paper consensus?

Most if not all these consultative meetings take place during working hours only, where Health Ministry officials could of course participate full time. But here is the crunch. Not many other stakeholders have sufficient manpower and knowledgeable experts or representatives who could attend such important meetings for weeks on end, and also over extended periods. Of course, one can argue that if parties are interested enough, they should sacrifice for the sake of the nation on something so important. But in reality this is easier said than done.

However, the main bone of contention is the sort of dialogue or consultation that these technical working groups (TWGs) address. Most participants lament the fact that the policy ideas and frameworks have already been fixed, and that participants are simply there to be merely made to understand the technical issues involved, and to tweak the minutiae of forecasted plans. there is little or no leeway to address disagreements and/or to seek alternative views in terms of policy direction or the best way forward—in other words, there is little tolerance for any dissent or variation.

Participating delegates are simply ushered along trajectories of planned reform pathways, which are then rubber-stamped as having been party to these so-called consultations! This is one major reason, why many invited groups have stopped participating in earnest or even wanting to come forwards to contribute, when these potential differing viewpoints are simply ignored or brushed aside, or considered irrelevant, by the officials in charge…

So, despite earlier high expectations, the difficulty is in getting enough interested parties and participants to consistently come forward to study and represent the vested groups sufficiently, to meaningfully address all the issues and implications of these crucial public consultations. So it is arguable if this current approach is an adequately thorough or fair process that is intended for deciding and planning what is best for the nation!

To cap the limitations of such discourses, there is also that (OSA) that participants have to comply with! with something to hugely critical, how can this be secretive and not be freely shared just because, these have not been cast in stone yet, as rationalized by some health officials, when complaints were made?

The cost containment argument does not quite compute…

But let’s get to the bottom of the government’s main contention that our health system is unsustainable. is it really? The government’s main argument for this drastic health reform is that our health care costs have been escalating beyond its capacity to control and possibly to afford. What is interesting is that over the past two to three decades, the government’s contribution to healthcare budget has not significantly wavered from its customary two to 2.2 per cent of the GDP; the chunk of it all being utilised for the public healthcare sector.

The private sector has been encouraged to grow and develop as a complementary private sector financing initiative (PFI), but like all business or commercial enterprises, this model fosters escalating costs, albeit towards distributing the healthcare cost to those who could afford to contribute or pay more for themselves.

No one sets up any business venture to lose money; all are in it for personal or corporate gain. But by offering a modicum of perhaps more personalised or more luxurious healthcare, these private health centres provide outlets for those who desire just such an experience—the better-off can choose to pay more to receive “more” arguably.

Thus, this appears to be a form of unspoken tariff on the rich, to allow market forces and the better-off to choose and to cross-subsidise their own healthcare cost within their own means and ability-to-pay, while the government provides back up and safety net for the poor and the less endowed.

Over the years, however, the quantum from Malaysia’s general government revenues (GGR) has changed very little, while medical technology and newer therapies have leapt to new heights of sophistication and costs. This inevitably triggers greater public demand for higher and better quality medical care and treatment—everyone wants to live longer, and suffer less, even if these are crippling ailments, which were once considered terminal or incurable…

In large, the private sector growth has overtaken the slack public sector in terms of modernization of health services, which explains the reversal of private-public expenditure profiles from 2004 onwards; the private sector expenditure now tops 55 per cent of the Malaysian total health expenditure (TEH).

This also, unfortunately, serves as powerful push factor for the public sector to also rise up in tandem to catch up with the modernization and upgrading of their services—increased spending on facilities, diagnostic technologies and demanded therapies—e.g. MRIs, CT scanners, latest medical, surgical and/or radio-therapeutic techniques and expertise, including higher manpower and skills development/training and emoluments!

Officials have projected that by 2020, our health care bill could top RM90 billion (from the current RM35 billion) and that out-of-pocket payments would be around 48 per cent. But this is a theoretical assumption that the trajectory of healthcare cost continues as it has, with no major change or shift from either the government sector allocation or from private sector growth.

Health economists dislike disproportionate out-of-pocket (OOP) payment for medical care, because this reflects underlying disparity in the general public gaining or affording access to much-needed health care. High OOP payment for healthcare is believed to accelerate inequity trends and aggravate risks for medical bankruptcies. But this is seen predominantly in poorer third world countries than in more successful nations such as Singapore, Sri Lanka or even Vietnam, where OOP payments regularly exceed 50 or even 70 percent of the TEH. Malaysia is considered favourably, too, despite its OOP spending being around 40 per cent of TEH.

Our public health sector serves our public well

Another issue is the current strategy where much of the public sector services are so heavily subsidised, that there is worry whether there could be any further increased allocation from the government coffers. This is particularly relevant because our government is grappling with limited success to reduce its national budget deficit against pressing and competing demands. Healthcare spending has unfortunately and misguidedly been put on the focus point for reduced government “subsidy”.

As it stands, only a paltry two per cent is recovered from all the spending in the public health sector. This lack of copayment returns on the part of public users of these services has made some of our policy makers wonder if this is the right direction of the public health sector, which has been trying to modernise and strengthen, and perhaps become more cost-effective and financially independent—some officials would like to make this public sector more competitive as a corporate body, hence the not unwarranted public or NGO fears of privatisation or corporatisation!

However, this consistent lack of capacity of public sector patients to contribute back the costs of the services received, actually underscores the viewpoint that most Malaysians who utilise these services do so because their access choice is largely determined by their inability-to-pay otherwise, rather than their wishing to game the system unfairly! Most, if not all, could not afford alternative private care, otherwise!

Simply put, people use these public sector health facilities because these are convenient and are almost free despite the inconveniences, the wait times, the irregular access to a consistent healthcare provider or doctor, the cheaper generic medications, etc. This is not to imply that the services provided by the public sector are in anyway inferior or substandard. But the reality is that this service is arguably not the preferred one if they could afford otherwise. This explains why some 65 per cent of our Malaysian public across all ethnic or social groups use private general practitioner (GP) services nationwide — because these are more attentive, more personal, still relatively affordable, and preferred!

In Malaysia currently, it is estimated that our less well-off citizens form some 40 per cent of the population. however, this less well-endowed group continues to be able to gain access to public sector services without suffering the plight of having to stay away due to cost constraints — this is indeed one of our great strengths. (Conversely, this is a common problem among the poor worldwide where no universal access to healthcare is guaranteed.)

Our health officials acknowledge that this easily accessible (and nearly free) public sector health service is one critical aspect of the public’s expectation: That this is precisely the social safety net that it should deliver and not to curtail or eradicate in the guise of subsidy reduction! Healthcare is a fundamental societal expectation and a right (not a dispensable luxury!), and enlightened governments should allocate more rather than less toward this social good. The public expects this, and no less!

Thus, the public in general expects that such a system be continued as justifiable social services for citizens, taxpayers and the needy of the country. indeed, most people, even if they do not now use these public sector services, feel that the government has a fiduciary duty to provide such healthcare services as mandatory back-up or safety net alternatives, even if only two per cent are recovered for all the public sector expenditure by the government.

The very fact that the almost fully-subsidised public sector services cater to the predominantly poor (and therefore, non-taxpaying citizens), makes this an inherent and natural cross-subsidy, which tends toward progressive equity in health care practice and financing.

There is, at present, no other simpler way for this to be separately reimbursed for this group of people who already do not contribute sufficiently to SOCSO, EPF, and are not eligible for or exempt from taxation. Thus, higher-earning taxpayers are already cross-subsidising this group of the poor via general government revenue allocations; while they (the better-off) still have a choice to access the preferred private sector either out-of-pocket or through some co-payment from third party payment mechanisms, including the much maligned health insurance!

Thus, our public health sector has an already inbuilt pro-poor system, which renders this social equity mechanism more progressive. This is certainly in the correct direction. there is public expectation that increase and not decrease in the quantum of allocation of government funds (general government revenues (GGR) from indirect or direct taxes) toward healthcare, is the preferred approach as part of the social services mandate of government.

Moreover, there is great reluctance on the part of the public of having to contribute more in terms of direct taxes (mandatory health insurance or any other form of goods and services tax), which generally affect the poor more than the better-off.

Proportionality of personal and individual taxes tend to affect the poor more because of their lower quantum of limited or no disposable or discretionary income, outside the realm of bare minimum basic livelihood essentials. The poor has a disproportionate share of indebtedness with little or no spare cash for anything else!

After taking care of livelihood and family maintenance necessities, the poor has hardly any excess or even no disposable income. Therefore, any further additional or mandatory household or personal tax/contribution would bite lopsidedly and painfully into these already-meagre funds. This leads to the concept of “ability-to-pay” considerations when it comes to economic activity, particularly relevant when it concerns health care.

* This article is the second in a five-part series. Part 1 is available here.

* Dr David Quek is past-president of the Malaysian Medical Association, but the opinions expressed are strictly his own and does not reflect those of the MMA.

* This is the personal opinion of the writer or publication. The Malaysian Insider does not endorse the view unless specified.

Mini-med health plans tend to appeal to industries such as retail, temporary staffing agencies and food service, according to the consumer group. The employers want to show that they have something extra to offer their staff, but, in reality, the plans offer little to no coverage, said report author Nancy Metcalf, senior program editor at Consumer Reports who writes the “Ask Nancy” blog about health insurance.

“There is this persistent dream of consumers that, if they only look hard enough, they’ll find really good insurance that costs a lot less,” said Metcalf. “It’s not going to happen. There’s no such thing as a bargain on health insurance. if it’s cheap, it’s cheap for a reason.”

Mini-meds offer a limited benefit health plan with extensive restrictions to those under the age of 65. Most plans cap benefits at a few thousand dollars per year. while many of these companies maintain that these plans are better than no insurance at all, Metcalf argues that some people may be better off without any insurance rather than making monthly payments to a plan that will probably not give adequate coverage when needed.

“In my view, people are better off putting whatever you would have paid to that mini-med in the bank in case something happens in the future,” said Metcalf.

Of course, Metcalf said that this is a last resort.

“This is an excellent report,” said Jonathan Weiner, professor of health policy and management at Johns Hopkins Bloomberg School of Public Health. “It’s great to see a clear discussion about these type of plans. they are not well-understood or widely publicized.”

Major insurance companies, including Cigna and Aetna, offer mini-med plans that allow for minimum and capped benefits. Robert Zirkelbach, press secretary for America’s Health Insurance Plans, the national trade association representing the health insurance industry, said many states use these types of plans to expand coverage for uninsured Americans.

“For many seasonal, part-time, and temporary workers, these types of plans are their only source of affordable health care coverage,” said Zirkelbach. “If employers are no longer allowed to offer these plans, many workers could lose the coverage they have today – breaking the promise that those who like their coverage can keep it.”

An Aetna spokesperson said the company recognizes that “limited benefit plans are not for everyone,” but the limitations are labeled clearly on the first pages of the plan’s summary.

“We believe that every American should have comprehensive health insurance and we have actively advocated for health care reforms to make that happen,” Aetna said in a statement. “In the current marketplace, however, limited benefit plans continue to meet a critical need for people who may otherwise not have access to, or be able to afford, health insurance.”

Cigna did not return ABC News’ request for comment.

These types of limited insurance come in two flavors: Discount cards and fixed indemnity plans, said Metcalf. A fixed indemnity plan will pay up to a certain amount for covered events. A discount card gives discounts for the full amount of medical services.

“Health insurance plans are structured to protect you when you’re sick,” said Metcalf. “But these make people so much more vulnerable if they actually get sick.”

While Metcalf said people should never purchase such plans, Weiner disagreed and said some people might benefit despite the limited benefits.

There are a couple of tricks of the trade, some of which are pretty obvious once you give them a bit of thought. The first and most vital tip is not to over wash your hair. Your head produces oil to protect your hair and it does that because it thinks that hair is crucial to help it control the temperature of the brain.

OK, these days we can put a hat on or erect a parasol, but it takes the body a long time to change. The point is to not wash all the oil from your hair too often. you want to wash the dirt off your hair but not all the oil.

Therefore, rub the shampoo into your scalp and not into your hair. as the shampoo runs off your hair it will take the dirt off your hair with it but just some of the oil. This makes a huge difference.

The tip above is the most important bit of advice because it applies to whichever shampoo you buy, but the next tip applies to what shampoo to purchase. do not skimp on shampoo if you would like lovely-looking hair.

Do you remember the days when you had to wash your hair, rinse it and then apply conditioner and then rinse again? well those actually were the good old days as far as hair is concerned. These all-in-ones work on the principle that the conditioner will not work in the presence of oil and the shampoo will not work if there is no oil.

This means that on the first wash, half the shampoo is wasted, but the shampoo has to scour your hair for the second wash (conditioner) to work. On the second wash the conditioner does its job, but the shampoo half goes down the drain having done nothing.

In other words, your inexpensive container of shampoo with conditioner costs double as much as you paid for it, so why not buy separate shampoo and conditioner in the first instance?

The combined shampoo and conditioner is a con because it makes you think that you are saving time and thereby getting something for nothing. you are not.

The best advice you can get for your hair is to purchase a mild shampoo without conditioner. By all means buy one that says that it is better suited to your type of hair if you like. then do some research on your hair type and natural colour on the Net and make your own conditioner or purchase one.

Individuals used to use vinegar, beer, dandelions and all sorts of things and one that I have recently come across is Butterfly Pea. do not become guiled by adverts and time saving if you really like your hair

Owen Jones, the author of this article, writes on a number of topics, but is now concerned with the cause of macular degeneration. if you would like to know more, please go to our website at Macular Degenerative Disease

20 years ago, I held the view that as a technical matter, some form of requirement to purchase insurance was needed in a near-universal insurance market to avoid massive instability through “adverse selection” (insurers avoiding bad risks and healthy people declining coverage). At that time, President Clinton was proposing a universal health care plan, and Heritage and I devised a viable alternative.

My view was shared at the time by many conservative experts, including American Enterprise Institute (AEI) scholars, as well as most non-conservative analysts. Even libertarian-conservative icon Milton Friedman, in a 1991 Wall Street Journal article, advocated replacing Medicare and Medicaid “with a requirement that every U.S. family unit have a major medical insurance policy.”

Many writing on the topic attribute the origin of the individual mandate to Butler, some to Mark Pauly (a conservative finance guy out of Wharton) and others believe it was an idea that had just been tossed around among conservative intellectuals like Friedman for many years. regardless, it is clear that Butler played an instrumental role in promoting the individual mandate. he does claim it was different than the current mandate.

first, it was not primarily intended to push people to obtain protection for their own good, but to protect others. like auto damage liability insurance required in most states, our requirement focused on “catastrophic” costs — so hospitals and taxpayers would not have to foot the bill for the expensive illness or accident of someone who did not buy insurance.Second, we sought to induce people to buy coverage primarily through the carrot of a generous health credit or voucher, financed in part by a fundamental reform of the tax treatment of health coverage, rather than by a stick.and third, in the legislation we helped craft that ultimately became a preferred alternative to ClintonCare, the “mandate” was actually the loss of certain tax breaks for those not choosing to buy coverage, not a legal requirement.

on his first point, it has been clear from the beginning that the mandate was intended to help address the free rider issue. That is no different than what it was supposed to do when designed by Butler. the primary difference seems to be in the amount of coverage. Heritage supported mandated catastrophic coverage (not well defined) as opposed to the more comprehensive coverage in the ACA. he forgets that the Bronze level coverage in the ACA should approach costs similar to a catastrophic plan.

Next, the ACA offers subsidies also. the subsidies vary by income, but they are carrots just like in the Heritage plan.

The stick part can be lumped in with addressing Butler’s third point. his mandate would have meant a loss of tax breaks, you would pay more tax, if you did not acquire insurance. the ACA would impose a fine (it has been suggested that it more closely approximates a tax). both of these punishments would be legally enforced. I suspect they would both cost about the same. if there is a distinction between these two plans, it is one without a real difference. Dont buy insurance, and you end up losing money, call it what you will.

Butler goes on to engage in egregious butt covering.

Moreover, I agree with my legal colleagues at Heritage that today’s version of a mandate exceeds the constitutional powers granted to the federal government. Forcing those Americans not in the insurance market to purchase comprehensive insurance for themselves goes beyond even the most expansive precedents of the courts.

it is constitutional to require catastrophic health insurance, but not comprehensive insurance? I do not find that even remotely credible. Why not just say, “I changed my mind”. Well, he sort of does.

And there’s another thing. Changing one’s mind about the best policy to pursue — but not one’s principles — is part of being a researcher at a major think tank such as Heritage or the Brookings Institution. Serious professional analysts actually take part in a continuous bipartisan and collegial discussion about major policy questions. we read each other’s research. we look at the facts. we talk through ideas with those who agree or disagree with us. and we change our policy views over time based on new facts, new research or good counterarguments.

it really is hard to admit when one is wrong. it is very difficult to concede that one’s principles have changed. Butler should just admit that he now believes that a mandate for health insurance is wrong. he used to believe that it was constitutional. Or, he should come out and say that he still believes a catastrophic insurance mandate is constitutional, and explain why one mandate is acceptable while the other is not.

given this history, in Butler’s own words, I think we can see that the ACA is a plan that was built, substantially, upon ideas that represented conservative ideas during the last health care reform attempt during CLinton’s presidency. it was not a radical new plan, but one that built upon ideas from past reform attempts, consciously adopting conservative ideas in the hope that it would generate some support from those who developed and supported those ideas. the writers of the ACA just didn’t know that everyone across the aisle would change their minds, on both policy and principle.