8 Things CFOs Must Know About Health Reform

Whether a Chief Financial Officer is running the fiscal operations of a hospital system, an insurance company or a company that simply employs individuals with health coverage, the decision-making process for sustainability is changing at a rapid pace. However, after years of hearing about reformation in the health system, broad, sweeping and revolutionary changes are finally happening. Major shifts are also occurring in the population, as well as technological advances that will disrupt the entire premise of a four-walled institution for care and the very model we use for health delivery.

Health care in the US is a business – a multi-billion dollar business – and understanding the financial implications of health reform will make or break every CFO. Knowing that health access, demand, quality and payment changes are inevitable there is an immediate need for CFOs across the ecosystems to embrace and plan for transformation.

1. You have too many beds.
   While many hospital leaders won’t accept this at face value due to lengthy wait times, surgical demands and desire to shift beds, the truth is there are too many beds in a lot of hospitals. Between transferals to the outpatient setting and telemedicine, the need for expensive inpatient beds is declining. Additionally, hospital leadership are increasingly finding that they face problems with state authorities when they apply to move beds. Most recently at the University of Chicago, where 338 beds were being used for a 304-person utilization pattern, the state rejected a University application to move surgical beds.
2. Food, housing and transportation of patients is your problem.
   As Americans begin to define and attempt to tackle community and population-based care, the access individuals have to quality food, affordable housing and efficient transit matter.  No one living in a food desert will have the same health outcomes as someone living next door to a Whole Foods, just as an individual with a new car will always be more consistent in making appointments and picking up prescriptions than someone who has to access three public transit buses for the same activities. Real patient engagement and activation begins with understanding the environment of each patient.
3. Your patient demographics are shifting, and so too should your leaderships. As the US continues to brown, hospital leadership must be representative of the population to understand and meet need. At a recent Modern Healthcare Top 25 Minority Executives session, an awardee remarked that the United States is now a country of minorities, and “our leadership as minorities is our future for health outcomes.” With this in mind, it is inevitable and paramount to success that the leadership of any organization resembles and represents those it serves, so it makes the financial investments and decisions that influence the community.
4. More bodies in beds will never work again.
   Value-based purchasing means that a warm body in a bed not only drives costs higher for the payer, but that the longer a patient remains in the hospital – or the more often they return – the more penalties that accrue. Therefore, the goal should not be for more bodies, but for cost-effective bodies. Depending on the community serviced, this can mean desire for more Masters Athletes, specialized services or elective services. Additionally, as we shift to a world where technology enables more clinical procedures and recovery to be done in the outpatient setting, or at home, and expensive inpatient procedures decrease in volume and reimbursements, hoping to fill beds is futile.
5. Alignment with physicians is nonnegotiable.
   No leader can effectively attain a goal without buy in from those who carry out the work.  However, it is important to be aware that “physician alignment” is a term that causes almost all physicians to turn and walk the other direction out of fear that this indicates buying their autonomy and dictating their day-to-day, moment-to-moment ability to practice. According to Healthcare Financial News the implications of physician behavior are so important in 2014 that more revenue than ever will be spent recruiting physicians who see the world the same way you do, which is not very different from how corporation CFOs think about their employee hires.
6. As consumers take on more and more pay responsibility, unexpected payment shifts will keep occurring.
   Many experts estimate that defined contribution, health insurance exchanges and the growing individual health insurance market means that patients will become more informed about spending their health care dollars, and therefore, more unwilling to spend. The future of reimbursements and pricing strategies is presently a puzzle wrapped in an enigma because of extreme uncertainty. However, it is general knowledge that Medicare and Medicaid reimbursements are going to continue decreasing, with the American Hospital Association and Moody’s already estimating an, “unequivocally negative” outlook for hospitals on the reimbursement fronts.
7. Technology and data utilization can save you money.
   While the learning curve with new technology can be excruciating and the meaningful utilization of collected information seems daunting, everything from workflow to health activities and employee/patient engagement can be monitored – and altered in real time – using new technology. Moreover, the more information that is known today, the better predictive analytics and behavioral change that can be made tomorrow. However, as the amount of technology available to leadership continues to grow exponentially, the purchasing of new tech will be a balancing act between what is a passing fad versus what is sustainable and transferable.
8. Your EHR is going to cost you. Big time.
   Now this seems obvious to most hospital CFOs, as they have already seen the initial price tags that come with implementing a “holistic” electronic system. However, the most costly elements may not yet be realized. As mergers and acquisitions continue, technology advances and EHR capabilities increase, the need to refresh systems will continue.  At present there is not one system that meets end-to-end patient or provider needs, leaving the ecosystem open for further disruption, which inherently includes more interoperability, more upgrades, more plugins and more costs.

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Health Insurance Benefits – Can You Have It Your Way?

As the percentage of large employers that consider a shift to defined contribution and/or private exchange increases, the number of options – and flexibility in those options – must also increase. Consideration for those options rose last year from 14% to 18% among large employers (500+ employees). Further, those who are considering the move to a private exchange want to because of their desire to offer more and better plan options, as well as realize cost-savings. Shifting to the defined contribution framework allows employers to moderate their subsidies to employees, and employees to make better trade-offs among plan options. Additionally, by increasing choices, defined contribution makes it easier for employers to integrate their health incentive and wellness programs by layering them “on top” of the defined contribution.

With this economic opportunity in the market, it is imperative that health plans and enrollment become more tailored to individual and company needs, in addition to the one-size-fits-all solutions of the past and present.

Private health exchanges, according to bswift, like their new Springboard Marketplace, could be the platform to give consumers that greater choice and increase individual decision-making. Given that most large employers who are considering a defined contribution will remain self-insured, bswift is taking a calculated gamble that employers will continue to invest in cost management solutions such as incentives, wellness programs, consumerism as opposed to simply shifting costs to employees under the “fix it and forget it” cost sharing approach suggested by some competitors.

Customize Your Cart

The Springboard Marketplace that bswift has created has the online functionality healthcare.gov could only have dreamed of, and the choice construction of a grocery store.  In fact, the terminology the company uses alludes to “Stocking the Shelves” with your benefit choices and “Shopping” for your ideal group of benefits. This is all done through the interactive benefits advisor, Emma, who walks employees through an online step-by-step process to fill their cart with health care options.

For those aware of bswift’s background as a tech company it may not be a surprise that the software and services offered are aimed at streamlining a very sophisticated system, and making the user experience easy. And for those that know the company’s Executive Director of Exchange Solutions Brad Wolfsen, the shopping experience and ease of transition into a new set of consumer options will easily resonate. Mr. Wolfsen, before joining the team, built and led Safeway’s wellness and retail strategy programs, and was the President of Safeway Health.

According to Mr. Wolfsen, the real benefit he sees to bswift’s products are that they, “allow employers to focus on equity for employees and shift to a retail view on providing health benefits.”  Or, as the Society for Human Resource Management labels it, From Parenting To Partnering.

New Plans Equal New Decisions

With a growing demand for health benefit options that resemble a choose your own adventure book, but with a set amount of money to spend, the development of software must also be functional for employers and employees. The Springboard Marketplace has been constructed so that functionality can simply be turned on and off, so that choices are simplified. Additionally, since there is not a standard approach to benefit choices and many legacy systems that have to be revamped due to mergers, acquisitions and partnerships, greater automation for employers means less paperwork for HR departments. By making workflow, reporting and administrative work more efficient through automation, cost-savings increase even further.

“The best and brightest clients are currently driving what is in the bswift system now,” says Mr. Wolfsen. “As we move towards expanding the suite of benefit options and meeting compliance standards, we are also investing in the shoppers experience.”

He, along with his colleagues at bswift, believe that their tech company is nimble in ways that others are not, and that with the help of their platform and Emma, more and more employers will begin the migration to defined contribution and private exchanges. If true, that growing shift could redefine how health benefit decision-making is done by employees in the future.

 

Mental Health Loses Funding As Government Continues Shutdown

In the months leading up to World Mental Health Day, DC has been shaken by a series of violent events that ended with innocent lives lost and our country’s mental health services called into question. During this same time period, Washington, DC has been consumed by a government shutdown, with lawmakers and policymakers trying to determine how to rein in our country’s financial burdens and overspending. Unfortunately, as federal and state governments look to cut budgets at every turn, mental and behavioral health services are often on the chopping block first. Financial cuts, compounded with US stigma often applied to mental health troubles and disparate access to services across the county, mean that those who need services most are often those left without proper care.

August though October brought DC into the spotlight for many reasons, the saddest of which is the violence that was covered by mass media as two shootings occurred. In one case, Aaron Alexis, a 34-year-old, perpetrated a mass shooting that left 12 people dead, in Washington’s Navy Yard. Previous to the shooting, it was reported that Mr. Alexis was treated at the VA for mental health issues including sleep disorders and paranoia, but had not lost clearance.

Miriam Carey, also 34, reportedly had an unhealthy obsession with the White House when she drove her car into the White House gates and led police on a chase around DC before being killed. Although she had no reported psychosis or supposed violent intent, it was noted in the months leading up to the incident she believed that the President had beenstalking her and might have suffered from postpartum depression. When killed by authorities on Pennsylvania Avenue, she had her 18-month-old child in the car.

Budget Cuts

Although societal stigma and knowledge of where to access behavioral and mental services are often barriers to care, budget cuts continue to make seeking care more difficult. Whether this be through decreases in available services, lack of providers due to poor reimbursements or less preventative actions in communities, the impact of mental health funding shortages is great. According to the National Alliance on Mental Illness, “increasingly, emergency rooms, homeless shelters and jails are struggling with the effects of people falling through the cracks due to lack of needed mental health services and supports.”

In the last five years, significant budget cuts have befallen mental health programs and services. From 2009 to 2011, states cut mental health budgets by a combined $4 billion- the largest single combined reduction to mental health spending since de-institutionalization in the 1970s. In Chicago alone, state budget cuts combined with reductions in county and city mental health services led to shutting six of the city’s 12 mental health clinics. These closures, along with other public and private center closures in Chicago, have eliminated vitally needed services, especially on the south and west sides where they are indispensable.

Threats of sequestration in 2013 had a significant impact on people’s ability to access mental health services and programs, including children’s mental health services, suicide prevention programs, homeless outreach programs, substance abuse treatment programs, housing and employment assistance, health research, and virtually every type of public mental health support. The Substance Abuse and Mental Health Services Administration(SAMHSA) claimed it alone would be cutting $168 million from its 2013 spending, including areduction of $83.1 million in grants for substance abuse treatment programs.

Consequences

Despite the need to balance budget and make all health care services more efficient, many argue that society has better long-term outcomes if more federal and state dollars are allocated to mental and behavioral health care. This includes preventative services as well as mental health testing and treatment.

Because individuals with untreated mental illness often find themselves in emergency rooms, homeless shelters and prisons, the societal cost of prevention and treatment may be exponentially less than funding those other outlets and catchment areas. This is especially true in the case of children, who face cycling in and out of the system throughout their lives if left untreated.

These costs can be exceptionally large over the lifetime given that the National Institute of Mental Health (NIMH) estimates that two-thirds of children with lifetime mental health problems never receive treatment. This takes substantial emotional and financial tolls on individuals and families, as well as the broader society. However, programs that address the mental health needs and provide services for youth show better outcomes in health and education that carry over the lifetime. For example, in the University of Chicago’s Crime Lab, therapy is being used to curb youth violence, especially amongst those with behavioral and mental health care needs.

Additionally staining on the mental health care system is that during times of recession and budget cuts the caseload for mental health actually increases. It has been estimated that during this most recent recession, the caseload of community mental health services alone has increased almost 50 percent. This increase has most notably been seen in the Native American community, where suicide prevention is an essential part of the cultural health care demands.

Everyone Benefits

The NIMH contends that one in 17 people suffer from a “seriously debilitating mental illness,” we as a society are accountable for ensuring that those in need have resources for care. Not only does access to quality mental and behavioral health care ensure that individuals are being properly treated, but that America as a whole saves money and resources caring for those in need in other, more expensive settings. It may further prevent violent acts like those in DC from happing.

On this World Mental Health day think about the ways in which access to and support of mental and behavioral health care can be improved in your community.

 

President Obama Fails To Explain Tech Glitches And Solutions In ACA Speech

Monday at 11:30am EST, President Obama spoke in the Rose Garden about the recent troubles with health insurance exchange enrollment and websites. With a team of young people standing behind him and Janice Baker at his side, the first person in the state of Delaware to successfully enroll in the exchange, President Obama said he was speaking to every American wanting to get affordable health insurance. He claimed that in the last three weeks, despite the horrific technological problems with the websites, that “half a million consumers across the country have submitted application through federal and state marketplaces.” He further touted that the “federal site alone has been visited 20,000,000 times” in the last three weeks. Unfortunately for those American’s who are really interested in signing up on the exchange sites, he glossed over the depth and breadth of the current troubles, giving a speech that sounded more like a State of the Union address with small-business examples and reading letters written to the White House.

President Obama also alleged that no one wants to see the exchange sites improve more than the federal government, noting that, “the website has been to slow, and people have been getting stuck during the process.” He also said that it is the mission of the administration to make them “more better,” with visible cringing from the audience, but claimed failures were due to response rates. He said the public response was “overwhelming, which has aggravated the underlying problems.”

However, he failed to go any further to explain what those other underlying problems were or when specifically they will be fixed. He did say that while HHS and contractors such as CGI Federal are working out the “kinks,” American’s should be patient. He claimed that “if the product is good, [American people] are willing to be patient,” suggesting that there will not be a delay for the individual mandate.

Nevertheless, he followed this by assuring the public that unlike Black Friday sales, the insurance plans will not run out like purchasing a new PlayStation – adding to the list of items the administration has compared exchange sites to, including iPhones and travel websites.

Despite his promises of improvements and putting the “best and brightest” on the job, CNN and other sites have insisted that the inherent technological and platform problems with Healthcare.gov will not be resolved anytime soon. This begs the question, that if the federal government is now searching for the best and brightest to correct the estimated 5,000-5,000,000+ lines of coding that need to be fixed on the federal site alone, who was working on the original platforms?

As he continued his speech, the President reminded the American public that although the websites for enrollment are not as, “quick, consistent or efficient as we want,” that the exchange sites are far more than “just a website.” He noted that many pieces of the Affordable Care Act (ACA) are already in place and being utilized by millions of Americans. He addressed pre-existing conditions, youth under the age of 26 and several other provisions that are already being rolled out by federal law, and the successes they have seen there.

He noted more examples of ACA triumph in Oregon, where he maintained that the exchange, “has cut the number of uninsured people by 10% in three week,” which is about “56,000 more Americans” with health insurance coverage.

During the speech, President Obama also tried to clarify the exchanges or marketplaces by describing them to the public as becoming part of a “big group plan… that bargains on your behalf for the best deal in health care.” He said that by doing so, insurance companies have created new products and options that strengthen market forces, leading to better deals.

He went on to say that without a doubt, “prices have come down,” further claiming that “when you add the next tax credits (those not yet implemented)… then the prices come down even further.”

The President rounded out his talk by noting the Republican party’s opposition to the ACA and how willing they were to “shut down the global economy” to fight against the ACA. A move, he claimed, that shows just how unwilling Republicans are to negotiate on legislation intended to, “free families from the pervasive fear that one illness one injury will cost you everything.”

While that may be the goal of the Affordable Care Act, the underlying technological and coding problems may prove to make that impossible.

 

Lasting Effects: Health Impact On First Responders

September 14

The days after September 11^th, 2001, the city of New York was enveloped in a blanket of ash. Rescue workers spent hours, days, even months without rest sorting through rubble and dust, exposing themselves to all kinds of physical dangers. These images are well documented in newspapers, television images and museums. But the haunting images from the aftermath, including the one of firemen I keep in my kitchen, do not tell the ongoing story of the men and women who risked their lives, physical health and mental health to dig the magnificent city out of the ash.

Despite the immediate coverage of heroism for the country’s rescue workers, very few have taken time in the last 12 years to fully research the physical and mental toll taken on those individuals that risked their lives on September 12^thand the following days. According to the City’s Department of Mental and Physical Hygiene “thousands of individuals—including rescue, recovery and cleanup workers and people who lived, worked or went to school in Lower Manhattan on September 11^th—have developed chronic, and often co-occurring, mental and physical health conditions.”

Understanding The Impact

Most of what is known about the issues affecting thousands of domestic and international rescuers has been collected by the New York City HealthDepartment’s World Trade Center Health Registry. This Registry, which allows health professionals to track and investigate illnesses and recovery related to September 11^th also helps create guidelines that can save lives and reduce injuries in future disasters.Dr. Robert Gillio, who is significantly responsible for its creation claims that, “The Registry was not part of any preplanning. Nor was the care of the New York Police Department (NYPD) or construction volunteers. I got a panicked call from someone that knew I had developed a middle school lab kit enabled laptop with curricula for how to measure heart and lung function and learn how to protect them. It was something I created for my four daughters to make health and science education more interesting.”

Following that creation, Dr. Gillio says, “When I joined up with a team of volunteers screening NYPD officers, this early telemedicine app was used to create health records. We had the presence of mind to realize the vast differences in the levels of exposure and decided to create questionnaires for what is called risk stratification.”

From that point forward the Registry has providedguidelines for domestic and international health care providers to care for those who volunteered in the aftermath of September 11^th by creating flow charts, tracking systems and symptom coordination for individuals who may be experiencing conditions related to World Trade Center exposures. The database has collected information on more than 70,000 people over a decade and includes not just the official heroes of September 2001, the NYPD and the Fire Department of New York (FDNY), but also the volunteer and paid professionals that tended to health care at the site, search and rescue teams, demolition and hauling teams, those who cleaned apartments and residents that moved back into the neighborhoods.

First Responders

All of these individuals took health-related risks, risks that are hard for many of us to understand, but none more so than the first responders. I certainly would not be one to run straight into the face of danger, despite that being in my genes. Growing up in a family of firemen meant that we came to terms early on that loved ones would risk their lives to save others. However, the honor and pride these men have shown throughout our lives often leaves us in fear. My admiration for my Father’s inherent need to help others gave way at times to fears of losing my hero to saving the lives of others buried in ashes. When asked why he chose to become a fireman, my dad, Rodney Fender, humbly said, “It’s just who I am. I want to help people.” He went on to describe the feeling that overcame him as a fireman, the one to rush into danger, saying his logical reaction to the call was, “How the hell do I get in there, and how do I get them out safely.” His immediate response has never been to think about himself above others.

When asked about this innate desire to risk oneself, it became clear that my father, like many rescuers simply react in a way that brings out the best in human nature. A mentality of our heroes following September 11^th, who were still there working through the ash and rubble, was best summed up by my grandfather, Michael Fender, also a fireman who said, “It’s just your job as a person to help other people.” He went on to explain that first responders have a mindset like his, “You do what you can, when you can, how you can. That’s just how we work.”

Lifelong Effects

September 11^th was a day that changed American lives forever, one that shook our faith in humanity to its core. Like all US Citizens, mental health and safety were altered in significant ways during that time of fear. For the rescue workers though, the risks of danger did not end with the last plane crash or the decision to go to war. For the first responders, volunteers and health care professionals and researchers, September 12^th marked another day to face physical and mental health risks to save the lives of others.

The image of an ash covered park in New York City with firemen working tirelessly in the background has been in my kitchen for many years, and serves as a daily reminder to the resiliency of this country, its citizens, and especially its heroes. Although their images are almost invisible in that photograph due to the devastation surrounding them, they are there, digging the city out of the rubble and piecing the lives of others back together.

In a similar vein, Dr. Gillio sat down soon after the attacks to write Lessons Learned at Ground Zero, an essay to, “Help explain to my daughters why mom and dad were away at Ground Zero when planes were falling out of the sky near us in PA. That book found its way to the White House and lead to a request for participation in a series of discussions there regarding the role of the average person or local organization in disaster preparedness, response and recovery. Those lessons in 2001 changed my career from one that treated preventable disease to one that finds ways to discover who is at risk and to intervene to prevent a chronic disease or acute injury and to empower the individual to be the health hero for themselves and their community.”

His message, and that of my father and grandfather, is correct. The terrorist attacks in 2001 changed American life forever. But as health care experts, providers, researchers, policymakers and first responders, it is our duty to take the lessons we learned from those horrific days, weeks and months to build a better system of care. Our job is to use our skills and passions to improve our communities as a whole and prevent, as well as care for, one another as best we can.

For more information, the 2009 World Trade Center Health Registry Report and Findings can be found here: WTCHR.

 

The Real Obamacare

Even before the Affordable Care Act had become law, its opponents cleverly dubbed it “Obamacare.” Their intentions were obvious: to capitalize on a substantial proportion of the public’s disapproval of our President and conjure up images of “socialized medicine” simultaneously. To some extent, the tactic has worked. It’s unclear that opposition to the law was generated by the intentional misnomer, but a substantial proportion of Americans–somewhere between 40 and 60 percent, depending on who’s asking–are opposed to the law. Of course, it’s debatable how many of them actually understand the intricacies of the law, as polls also show broad support for many of its key provisions. Heck, even Mitt Romney–who has pledged to repeal the law if elected–likes many parts of it. (Of course, he should, he signed essentially the same bill into law into Massachusetts while he was Governor.)

President Obama has not shied away from the law’s GOP-given nickname, either. In fact, during one of the recent Presidential debates, he admitted that he liked it. After all, it is giving him direct credit for one of, if not the single-most important policy achievements of his first term. America had tried and failed to enact health reform for nearly a century. Obama helped to realize the dream. He has every right to be proud of that. But, the name is still misleading.

I’ve written about many aspects of this before. For example, I’ve said that it’s not entirely accurate to give the President sole credit. The really difficult work happened in Congress. I’ve also said repeatedly that this is not socialized medicine, but rather a last-ditch effort by the federal government to use the power of competition in the private insurance market to help save the American health care system. I’ve discussed how the closest thing to socialized medicine that was even considered was simply a program modeled after Medicare. That program, the so-called “public option” was ultimately removed from the bill in order to secure its passage to the disappointment of many progressive members of Congress.

In short, none of the things that were being hinted at, suggested, or downright lied about by using the name “Obamacare” have ever been a threat to opponents, because they haven’t been real. Examples abound, but foremost among these are the notion of “death panels.” Sarah Palin and Betsy McCaughey dreamed that one up, and Paul Ryan’s still been talking about it. Folks, it’s simply not true. What has happened, is that young adults can stay on their parents’ insurance plans until age 26, prescription drug coverage and preventive care have been made more affordable for seniors, and individuals can no longer be denied coverage for pre-existing conditions. But that’s only what’s happened so far. There’s more to come.

By 2014, the health insurance exchanges will be operational, and you’ll be able to find quality coverage for yourself and your family at a competitive rate. The Medicaid program will expand in most states to provide coverage to low-income Americans. And, if neither of those options helps you, you’ll be able to purchase coverage through a federally-sponsored multi-state insurance plan. This isn’t the public option, but it’s close. It will still be private coverage, but it will be contracted for by the federal government. If you have insurance through your employer now, you can think of this as another similar option, with the government serving in the same role as your employer currently does. What does it mean for you? More plan choices. Potentially lower costs through competition. A plan endorsed by the federal government that isn’t looking to cut corners to make a profit. This, folks, is the real Obamacare, and you should remember that on November 6th.

 

Mitt Romney For the Public Option?

When the Affordable Care Act was passed, it made it through without the so-called “public option” that progressives everywhere thought would save the U.S. health care system. Quite simply, the public option was to be a federal insurance plan that anyone could purchase, and it was considered a way to increase choice of plans for consumers while keeping insurers accountable by providing a competitive benchmark for cost and quality of coverage.

The problem was, the GOP decided that it hated the idea of competition. Not all competition, mind you, but any competition between the federal government and private industry. Never mind that this is precisely what they put in place themselves with the introduction of Medicare Advantage plans. When the other party’s in power, the playbook reads “Always say no” and thus, the rules changed. Now it appears that Mitt Romney, possible GOP nominee for the 2012 presidential election, favors competition again. In fact, it appears that he even favors the forbidden variety of government-private sector competition.

You see, last week, Romney outlined a plan to reform Medicare if he is elected. His plan gives seniors a voucher, the amount of which is based on their income, with lower income individuals receiving bigger payments, which they can then use to purchase health insurance coverage from either the government’s Medicare program or a private health insurer that offers a plan at least as good as Medicare. In theory, there would be competition, and prices would go down. That’s right, let our seniors shop for the best deal and let private insurers compete against the federal government for their business.

What’s likely to happen, though, is that private insurers either avoid the Medicare market altogether, or they cherry-pick the healthiest seniors to ensure they can turn a profit as we’ve seen happen with Medicare Advantage. In the former case, there will be no competition to drive down costs. In the latter case, the Medicare market will essentially be segregated into a healthier group with private coverage and a sicker group with traditional Medicare, which will have the effect of making insurers more money and sticking the federal government with the bill. The Romney plan attempts to get around this by requiring the private plans to accept everyone who seeks coverage, but how that plays out is debatable.

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