Democrats Have No Safe Options On Health Care

Democrats Have No Safe Options On Health Care

Even though most of the candidates have committed to some form of universal health care, the Democratic primary is turning into a debate about the future of the country’s health care system. Presidential hopefuls have proposed policies ranging from an ambitious four-year plan to transform Medicare into a universal single-payer system, in which the government pays for everyone’s health care and private insurance plans are effectively eliminated, to a more modest scheme that would leave the existing health care system intact but create a government-administered public insurance plan people could choose to purchase. But some of the candidates have been light on policy specifics, so it’s likely that health care will be a big topic at the debates and beyond.

In the abstract, focusing on health care makes a lot of political sense for Democrats. It was a top issue among Democratic voters in the 2018 midterms, and the Trump administration recently renewed its efforts to strike down the Affordable Care Act in the courts, which means the law could be hanging in the balance throughout the primaries and into the general election. A recent ABC News/Washington Post poll also found that Americans, by a 17-point margin, say that President Trump’s handling of health care makes them more likely to oppose him than to support him in 2020. By a similar margin, an Associated Press/NORC poll found that Americans trust Democrats more than Republicans on health care.

All of this means that Democrats are heading into the 2020 election cycle with a serious edge on an issue that has the potential to mobilize their base. But if the candidates pitch big, sweeping changes to the health care system without addressing voters’ concerns about cost and access, that advantage won’t necessarily hold up. And trying to sell Americans on a completely new system carries risks, even in the primaries.

Why do people care about health care so much?

First, it’s important to understand how health care has morphed over the past decade from just another issue to one of the issues voters care most about. In the 2018 exit polls, 41 percent of voters said health care was the most important issue facing the country, up from 25 percent in 2014 and 18 percent in 2012. (It wasn’t asked about in 2016.) And although Democrats are more likely to prioritize health care than Republicans, a Pew Research Center poll from January found that a majority of Republicans say health care costs should be a top priority for Congress and the president.

The reason? Health care is becoming more of a financial burden, according to Mollyann Brodie, executive director for public opinion and survey research at the Kaiser Family Foundation. Specifically, Americans’ out-of-pocket health care costs have risen significantly over the past decade, even for workers who get insurance through their jobs. In an economy that by many measures is doing well, health care — rather than something like taxes — is becoming one of voters’ most important pocketbook issues, she said. “If you’re worried about whether you or your loved ones can afford your next health care bill, that’s really a matter of life or death, so you can understand why this issue is moving to center stage politically.”

And Americans are increasingly likely to say that the government has an important role to play in ensuring access to health care. In November, Gallup found that 57 percent of Americans said they think it’s the federal government’s responsibility to ensure that everyone has health care coverage, up from a low of 42 percent in 2013. Support for the Affordable Care Act rose over the same period, too. But, notably, support for government intervention in the health care system was even higher before President Obama was elected and the ACA passed — in 2006, 69 percent of Americans thought the government should guarantee health care coverage.

While support for government involvement in health care is rebounding, it’s not clear how much change voters are really asking for. “The average American is first and foremost concerned about the financial problems facing their family,” said Robert Blendon, a professor of health policy and political analysis at Harvard. “They’re less worried about system-level concerns like health care spending and inequality. They want their existing coverage to be better and more affordable.”

What do voters want politicians to do?

Americans aren’t opposed to the idea of government-run health care, but there’s not a lot of consensus on what that would mean. For example, a recent Kaiser Family Foundation poll found that a majority (56 percent) of Americans favor a national “Medicare for All” plan. But according to a March Morning Consult poll, Americans are more likely to favor a plan that offers some kind of public option — a government-sponsored health insurance plan available in addition to existing private plans — over a system where everyone is enrolled in the same plan.

But this apparent contradiction makes sense, according to Brodie, because Americans are risk-averse when it comes to health care, and the switch to single-payer would affect far more people than the ACA did. Tens of millions of previously uninsured people received coverage under the ACA, but that number would be dwarfed by the 156 million people who get their insurance through their employers and could see their coverage change if the country switched to a single-payer plan. “Even if the current system isn’t working, transitions are scary,” Brodie said. “And people aren’t necessarily aware of what a national plan really means. When you start telling people that there might not be any more private insurance companies, that’s actually not a popular position.” For example, a January Kaiser Family Foundation poll found that support for a national Medicare for All plan dropped significantly when respondents were told it would mean eliminating private insurance companies.

And when asked what health care policies they want Congress to prioritize, Americans don’t list Medicare for All first. Instead, according to a recent Kaiser Family Foundation poll, they want Congress to pass targeted measures that would lower prescription drug costs, continue the ACA’s protections for preexisting conditions and protect people from surprise medical bills. Only 31 percent of Americans say that implementing Medicare for All should be a top priority for Congress, compared to 68 percent who want lowering drug prices to be a top priority. Moreover, prioritizing Medicare for All is politically polarizing: Only 14 percent of Republicans support putting that kind of plan at the top of the to-do list, compared to 47 percent of Democrats.

Some health care issues get only one-sided support

Share of Republicans and Democrats who say each issue should be a top priority for Congress, and the difference between the parties

Dem. Rep. Diff.
Making sure the ACA’s preexisting condition protections continue 82% 47% D+35
Implementing a national Medicare for All plan 47 14 D+33
Expanding government financial help for those who buy their own insurance coverage on the ACA marketplace to include more people 36 18 D+18
Lowering prescription drug costs for as many Americans as possible 77 66 D+11
Protecting people from surprise high out-of-network medical bills 55 45 D+10
Repealing and replacing the ACA 16 52 R+36

Source: Kaiser Family Foundation

However, smaller policy steps like lowering prescription drug costs and protecting people from surprise medical bills get more bipartisan support. Overall, Americans seem to be more concerned with fixing the current health care system than creating a sweeping new replacement — even if that replacement could address the issues they most want fixed in the current system.

What does this mean for the Democrats?

The complexity of Americans’ views on health care doesn’t change the fact that Democrats have a big advantage over Republicans on this issue, but it does mean that the individual candidates are in a tough spot because there’s no obvious unifying message they can adopt for the primary. And embracing a single-payer plan now could hand the GOP a weapon for the general election, allowing Republicans to frame the health care discussion around the Democrats’ controversial plan while glossing over Trump’s efforts to dismantle the ACA.

“The safest bet for a Democrat in the general election is to emphasize Trump’s track record on health care and say you’re going to make the ACA work,” Blendon said. The problem is that while that kind of argument might appeal to moderates, it’s likely to fall flat among a significant sector of the Democratic base that supports prioritizing a national Medicare for All plan over improving and protecting the ACA.

Democrats arguably still have an opening to make a case for a more ambitious health care overhaul, since voters still have relatively little information about what something like Medicare for All means. “It’s fine to support single-payer if you think that’s where the country needs to go, but you can’t just lean on principles like fairness or equality when you’re selling it,” said David Cutler, an economist at Harvard who advised Obama’s campaign on health care strategy. “You also have to tell voters, very specifically, what you are going to do to lower their costs and improve their coverage next year — not in 10 years.”

Even though Americans mostly prefer Democrats’ health care positions to the GOP’s, Democrats still risk alienating voters if they emphasize bumper-sticker slogans over concrete strategies for reducing the financial burden of health care. This is particularly important because their base of support for a single-payer system may be shallower than it appears, even within the party — especially when it comes to getting rid of private insurance. Big changes to the status quo are always politically challenging, but they may be especially risky when many Americans are concerned about losing the protections they already have.

 

 

 

Uninsurance of children, parents inched back up in 2017, report finds

https://www.healthcaredive.com/news/uninsurance-of-children-parents-inched-back-up-in-2017-report-finds/554590/

Dive Brief:

  • After improving for several years, insurance gains and participation in Medicaid and the Children’s Health Insurance Program tilted downward in 2017, a new Urban Institute report shows.
  • In the first three years following implementation of the Affordable Care Act, the uninsurance rate dropped from 7% to 4.3% among children and from 17.6% to 11% among parents, or about 40% for both groups. In 2017, however, the children’s uninsurance rate inched back up to 4.6%, or an additional 281,000 uninsured children, and parents’ coverage rate stalled.
  • Uninsurance rates rose both in states with and without the ACA’s Medicaid expansion, but the increase was more pronounced in states without expansion programs.

Dive Insight:

The findings jibe with recent data from the Centers for Disease Control’s National Health Interview Survey, which showed more than 1.1 million Americans lost health coverage in 2018, pushing the total number of uninsured from 29.3 million in 2017 to 30.4 million last year. Among surveyed adults between 18 and 64 years old, 13.3% were uninsured, 19.4% had public health coverage and 68.9% had private coverage.

The trend coincides with Trump administration efforts to weaken the ACA by eliminating several mechanisms meant to stabilize payers participating in ACA exchanges and pushing stripped-down, noncompliant health plans. The result has been rising premiums and a resurgence in the number of uninsured.

Adding to uncertainty about the ACA’s future is the U.S. Department of Justice’s support for a Texas federal district court that ruled the law unconstitutional without its individual mandate penalty, which a Republican-led Congress removed in 2017. A previous Urban Institute report estimated up to 20 million Americans would lose health insurance if the lawsuit prevails — a majority of whom are currently covered through Medicaid expansions and ACA exchanges.

While the ACA remains in legal jeopardy, Democrats and presidential candidates are looking at ways to increase the numbers of insured Americans, from shoring up the ACA to implementing some type of single-payer system or “Medicaid for All.”

According to the Urban Institute, participation in Medicaid/CHIP among children increased from 88.7% in 2013 to 93.7% in 2016, and from 67.6% to 79.9% for parents. Those gains reversed in 2017, however, with Medicaid/CHIP participation dropping to 93.1% among children and remaining unchanged for parents.

Among those who did not enroll in Medicaid/CHIP in 2017, 2 million children and 1.7 million parents were eligible for the programs — versus 1.9 million and a steady 1.7 million, respectively, in 2016.

More than half of the uninsured children and parents who were eligible for the Medicaid/CHIP lived in California, Florida, Georgia, Illinois, Indiana, New York, Pennsylvania and Texas, according to combined 2016-2017 data.

Parents were more than twice as likely to be uninsured as children in 2017. For example, children’s uninsurance rate was less than 5% in most states and under 10% in nearly every state, while parents’ uninsurance was less than 5% in just four states and over 10% in close to half the states, the report says.

The decline in improvement was worse among certain subgroups. “In 2017, the uninsurance rate was nearly 6% or higher among adolescents, Hispanic and American Indian/Alaska Native children, citizen children with noncitizen parents, and noncitizen children,” according to the report. “And consistent with prior years, one in six parents or more who were ages 19 5o 24, Hispanic or American Indian/Alaska Native, below 100 percent of FPL [federal poverty level], receiving SNAP [Supplemental Nutrition Assistance Program] benefits, or noncitizen were uninsured in 2017.”

 

 

 

 

 

 

Democrats Draw up their Healthcare Battle Lines

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Now that former Vice President Joe Biden has thrown his hat in the ring for the 2020 Presidential race, the healthcare policy differences between moderate and progressive factions of the Democratic party are becoming clearer. On Monday, Biden revealed the broad outlines of his healthcare platform, coming out in favor of a “public option” that would allow Americans to buy into the Medicare program, but would leave the existing employer-sponsored insurance framework largely intact. “If the insurance company isn’t doing right by you, you should have another choice,” Biden said in a campaign rally in Pittsburgh. Although his campaign did not announce details of the proposal, Biden seems to support the idea of offering a Medicare plan to employers and individuals through the Affordable Care Act (ACA) marketplaces.

As the frontrunner in the primary race, Biden’s support for this more moderate approach to coverage expansion will surely make him the favored candidate of healthcare industry interests, who have come out swinging hard against “Medicare for All” (M4A) proposals.

But his position earned him a swipe from progressive candidate Sen. Bernie Sanders (I-VT), who’s running second among Democrats in early polling. “It doesn’t go anywhere near far enough,” said Sanders of Biden’s proposal, “it will be expensive, [and] it will not cover a whole lot of people.” Sanders instead favors eliminating private insurance altogether and moving quickly toward a single-payer system built around universal Medicare coverage.

As the Presidential race takes shape, expect candidates to orient around one of these two poles: Biden’s moderate approach (O’Rourke, Buttigieg, Klobuchar); and Sanders’s more aggressive position (Warren, Harris, Booker).

Either position will present a stark contrast in the general election, as the Trump administration looks to reinvigorate the effort to strike down the ACA entirely. The 2020 elections are shaping up to be a pivotal moment for healthcare.

Digging into the details of single-payer healthcare

https://www.cbo.gov/system/files/2019-05/55150-singlepayer.pdf

Digging into the details of single-payer healthcare
 
Lawmakers on Capitol Hill rolled up their sleeves this week and began to explore what a shift to Bernie Sanders-style “single payer” healthcare would really mean. In a hearing before the House Rules Committee on Tuesday, Congress heard from proponents of M4A and policy experts about the implications of single-payer health coverage, at least as envisioned by a recent bill authored by Rep. Pramila Jayapal (D-WA).

Although the committee does not have direct jurisdiction over Medicare, and Jayapal’s bill may never be introduced onto the floor of the House (since it lacks support from the Democratic leadership there), the hearing gave lawmakers their first chance to publicly probe the proposal, with predictable positions staked out by Democrats and Republicans on the committee.

More hearings are likely later this year, including by the House Budget Committee, which this week received a report it requested from the Congressional Budget Office (CBO) on the topic of single-payer healthcare. While the report does not address specific details about the cost or tax implications of a shift to single payer, it nonetheless provides an outstanding primer on the key questions that will have to be answered as part of any serious attempt to pursue M4A.

The graphic below, taken from the CBO document, poses those questions in a clear and helpful way, and the full report lays out a framework for approaching them. It’s a sober look at the hard problems that need to be faced: provider payment levels, increased wait times, public vs. private financing, access to unproven treatments.

Whatever your view on the topic, we’d highly recommend reading the CBO report in full.

The CBO analyzed what it would take to shift to a single-payer system. Here are 5 takeaways

https://www.fiercehealthcare.com/payer/5-takeaways-from-cbo-s-analysis-a-single-payer-system?mkt_tok=eyJpIjoiTURRNU5HTmpZbU5tT1RFeiIsInQiOiJLcVdxN0dKUU5iaEdMTGtaMG9xbFdtdEgxdXJBbndhTUNyMWN6UTZzbGJhTHFkS3Z4eTRBZkFGNUxcLzlyZUxvMHpOUDRDbmptdGE4aHVoMk4wS1NTYUlWMFVPMmFxNEEzTkJcL1RDODhYa3psN0VkNFhFdTVqYjlDSHltaTdPMUFxIn0%3D&mrkid=959610

Image result for congressional budget office

As chatter about “Medicare-for-All” ideas heats up—at least among the field of Democratic presidential hopefuls—the Congressional Budget Office decided to offer its own take.

Well, sort of.

Wednesday, the CBO issued a report that dove into the key considerations policymakers might want to think about before they overhaul the U.S. healthcare into a single-payer system. Putting it mildly, they said, the endeavor would be a “major undertaking.”

They don’t actually offer up specific cost estimates on any of the Medicare-for-All bills floating around, though other researchers put Bernie Sanders’ Medicare-for-All plan at between $32.6 trillion and $38.8 trillion over the first decade.

But the CBO analysts did weigh in on a slew of different approaches to financing, coverage, enrollment and reimbursement that could be built into a single-payer plan.

“Establishing a single-payer system would be a major undertaking that would involve substantial changes in the sources and extent of coverage, provider payment rates and financing methods of healthcare in the United States,” the CBO said.

So what exactly did the CBO have to say about what it would take to create a single-payer system? Here are some key takeaways:

1. There could be a role for private insurance—or not

There has been plenty of heated debate around Medicare for All focused on the role that existing private coverage could—or could not—play in that system. Most insured Americans are enrolled in a private plan today, including about one-third of Medicare beneficiaries.

If they’re allowed, commercial plans could play one of three roles in a single-payer system, according to the report: as supplemental coverage, as an alternative plan or to offer “enhanced” services to members in the government plan. 

Allowing private insurers to offer substitutive plans is unlikely, because they could potentially offer broader provider networks or more generous benefits, which would draw people into them. A solution to this issue could be mandating that providers treat a minimum number of patients who are enrolled in a single-payer plan.

Private payers could also offer coverage for care that is traditionally outside of the purview of government programs, such as dental care, vision care and hearing care.

Supplemental plans like these are offered in the existing Medicare program, and several countries with single-payer systems allow this additional coverage.

For example, in England, private plans offer “enhancements” to members of the government plan, including shorter wait times and access to alternative therapies, But members of these plans must pay for it in addition to tax contributions to the country’s National Health Service. 

2. Other government programs could stick around

In addition to Medicare and Medicaid, the federal government operates several health programs targeting individual populations: the Veterans Affairs health system, TRICARE and Indian Health Services.

A single-payer system could be designed in a way that also maintains these individualized programs, the CBO said. Canada does this today, where its provinces operate the national system while it offers specific programs outside that for indigenous people, veterans, federal police officers and others.

There could also be a continuing role for Medicaid, according to the report. 

“Those public programs were created to serve populations with special needs,” the CBO said. “Under a single-payer system, some components of those programs could continue to operate separately and provide benefits for services not covered by the single-payer health plan.”

On the flip side, though, a single-payer plan could choose to fold members of those programs into the broader, national program as well, the office said. 

3. A simplified system could also mean simplified tech

Taiwan’s government-run health system has a robust technology system that can monitor patients’ use of services and healthcare costs in near real-time, according to the report.  

Residents are issued a National Health Insurance card that can store key information about them, including personal identifiers, recent visits for care, what prescriptions they use and any chronic conditions they may have.  Providers also submit daily data updates to a government databank on service use, which is used to closely monitor utilization and cost. Other technology platforms in Taiwan can track prescription drug use and patients’ medical histories.

However, getting to a streamlined system like this in the U.S. would be bumpy, the CBO said. It would face many of the same challenges the health system is already up against today, such as straddling many federal and state agencies and addressing the needs of both rural and urban providers.

But the payoffs could be significant, according to the report. 

“A standardized IT system could help a single-payer system coordinate patient care by implementing portable electronic medical records and reducing duplicated services,” the agency wrote. 

4. How to structure payments to providers? Likely global budgets

Most existing single-payer systems use a global budget to pay providers, and may also apply in tandem other payment approaches such as capitation or bundled payments according to the report.

How these global budgets operate varies between countries. Canada’s hospitals operate under such a model, while Taiwan sets a national healthcare budget and then issues fee-for-service payments to individual providers. England also uses a national global budget.

Global budgets are rare in the U.S., though Maryland hospitals operate under an all-payer system. These models put more of the financial risk on providers to keep costs within the budget constraints. 

Many international single-payer systems pay based on volume, but the CBO said value-based contracting could be built into any of these payment arrangements.

5. Premiums and cost-sharing are still in play, especially depending on tax structures

A government-run health system would, by its nature, need to be funded by tax dollars, but some countries with a single-payer system do charge premiums or other cost-sharing to offset some of those expenditures.

Canada and England operate on general tax revenues, while Taiwan and Denmark include other types of financing. Danes pay a dedicated, income tax to back the health system, while the Taiwanese have a payroll-based premium. 

The type of tax considered would have different implications on financing, according to the CBO. A progressive tax rate, for instance, would impose higher levies on people with higher incomes, while a consumption tax, such as one added to cigarettes, would affect people more evenly.

Policymakers will also have to weigh when to impose new taxes, shifting the economic burden between generations. 

The CBO did not offer any cost estimates in terms of the amount the federal government would need to raise in taxes to fund a single-payer program.

 

 

 

Wall Street is still selling off health care stocks

https://www.axios.com/newsletters/axios-vitals-64abbaf8-c86f-4ac1-8561-525b0fd33c25.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

Image result for medicare for all

Yesterday, UnitedHealth Group posted $3.5 billion of profit in the first quarter — its second-most profitable quarter ever — and collected more than $60 billion of revenue, Axios’ Bob Herman reports.

Yes, but: UnitedHealth’s stock price tanked by 4%, which consequently dragged down shares of the other major health insurers and hospital chains. Cigna’s stock price plummeted 8%, and Anthem and Humana were close behind. HCA tumbled 10%.

Driving the news: Wall Street remains fearful of “Medicare for All” becoming a reality, and UnitedHealth CEO Dave Wichmann tried to get ahead of the message by telling investors that single-payer would “jeopardize” people’s care.

  • Many investment bank analysts were perplexed by the sell-off, considering that UnitedHealth has more cash than it knows what to do with.
  • Steven Halper of Cantor Fitzgerald wrote to investors: “What more can you ask for? Take advantage of poor sentiment.”

The big picture: Medicare for All discussions matter far more to Wall Street right now, and that makes the industry’s Q1 financial reports a lot less important.

 

 

 

Considering “Single Payer” Proposals in the U.S.: Lessons from Abroad

https://www.commonwealthfund.org/publications/2019/apr/considering-single-payer-proposals-lessons-from-abroad

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ABSTRACT

  • Issue: When discussing universal health insurance coverage in the United States, policymakers often draw a contrast between the U.S. and high-income nations that have achieved universal coverage. Some will refer to these countries having “single payer” systems, often implying they are all alike. Yet such a label can be misleading, as considerable differences exist among universal health care systems.
  • Goal: To compare universal coverage systems across three areas: distribution of responsibilities and resources between levels of government; breadth of benefits covered and extent of cost-sharing in public insurance; and role of private insurance.
  • Methods: Data from the Organisation for Economic Co-operation and Development, the Commonwealth Fund, and other sources are used to compare 12 high-income countries.
  • Key Findings and Conclusion: Countries differ in the extent to which financial and regulatory control over the system rests with the national government or is devolved to regional or local government. They also differ in scope of benefits and degree of cost-sharing required at the point of service. Finally, while virtually all systems incorporate private insurance, its importance varies considerably from country to country. A more nuanced understanding of the variations in other countries’ systems could provide U.S. policymakers with more options for moving forward.

Background

Despite the gains in health insurance coverage made under the Affordable Care Act, the United States remains the only high-income nation without universal health coverage. Coverage is universal, according to the World Health Organization, when “all people have access to needed health services (including prevention, promotion, treatment, rehabilitation, and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship.”1

Several recent legislative attempts have sought to establish a universal health care system in the U.S. At the federal level, the most prominent of these is Senator Bernie Sanders’ (I–Vt.) Medicare for All proposal (S. 1804, 115th Congress, 2017), which would establish a federal single-payer health insurance program. Along similar lines, various proposals, such as the Medicare-X Choice Act from Senators Michael Bennet (D–Colo.) and Tim Kaine (D–Va.), have called for the expansion of existing public programs as a step toward a universal, public insurance program (S. 1970, 115th Congress, 2017).

At the state level, legislators in many states, including Michigan (House Bill 6285),2 Minnesota (Minnesota Health Plan),3 and New York (Bill A04738A)4 have also advanced legislation to move toward a single-payer health care system. Medicare for All, which enjoys majority support in 42 states, is viewed by many as a litmus test for Democratic presidential hopefuls.5 In recent polling, a majority of Americans supported a Medicare for All plan.6

Medicare for All and similar single-payer plans generally share many common features. They envision a system in which the federal government would raise and allocate most of the funding for health care; the scope of benefits would be quite broad; the role of private insurance would be limited and highly regulated; and cost-sharing would be minimal. Proponents of single-payer health reform often point to the lower costs and broader coverage enjoyed by those covered under universal health care systems around the world as evidence that such systems work.

Other countries’ health insurance systems do share the same broad goals as those of single-payer advocates: to achieve universal coverage while improving the quality of care, improving health equity, and lowering overall health system costs. However, there is considerable variation among universal coverage systems around the world, and most differ in important respects from the systems envisioned by U.S. lawmakers who have introduced federal and state single-payer bills. American advocates for single-payer insurance may benefit from considering the wide range of designs other nations use to achieve universal coverage.

This issue brief uses data from the Organisation for Economic Co-operation and Development (OECD), the Commonwealth Fund, and other sources to compare key features of universal health care systems in 12 high-income countries: Australia, Canada, Denmark, England, France, Germany, the Netherlands, Norway, Singapore, Sweden, Switzerland, and Taiwan.

We focus on three major areas of variation between these countries that are relevant to U.S. policymakers: the distribution of responsibilities and resources between various levels of government; the breadth of benefits covered and the degree of cost-sharing under public insurance; and the role of private health insurance. There are many other areas of variation among the health care systems of other high-income countries with universal coverage — such as in hospital ownership, new technology adoption, system financing, and global budgeting — that are beyond the scope of this discussion.