Category Archives: Medicaid Expansion

Damned If You Do, Damned If You Don’t

“You can always count on Americans to do the right thing – after they’ve tried everything else.”

Winston Churchill

“Our policy is to create a national health service in order to ensure that everybody in the country irrespective of means, age, sex or occupation shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available.

Winston Churchill

 

Veering away from the usual topics covered in this blog, I thought about some recent articles I saw about the attempt to repeal and replace, or to simply repeal the Affordable Care Act (ACA), which the current political regime wants to do.

The first article, in yesterday’s [failing] New York Times, warned that repealing the ACA would make it harder for people to retire early. Those who retire early, before reaching 65, can get retiree coverage from their former employers, but not many companies offer that coverage.

Those early retirees poor enough could turn to Medicaid, and everyone else would have to go to the individual market. Without the ACA, health care coverage would be more difficult to get, cost consumers more where available, and provide fewer benefits.

According to the article, if the ACA is repealed, retiring early would become less feasible for many Americans. This is called job-lock, or the need to maintain a job to get health insurance.

This is one of the concerns the ACA was supposed to address, in that it would reduce or eliminate job lock. Repealing the law could, according to the article, affect employment and retirement decisions.

The second article, from Joe Paduda, also from yesterday, reported that improving healthcare will hurt the economy, and Joe lays out the arguments for doing something or doing nothing to improve health care and what effect they would have on economic growth.

For example, Joe states that healthcare employs 15.5 million full time workers, or 1 out of every 9 job. In two years, this will surpass retail employment. As Joe rightly points out, those jobs are funded by employers and taxpayers. He suggests that some experts argue that healthcare is “crowding out” economic expansion in other sectors, thereby hurting growth overall.

But Joe also points out that by controlling health care costs, employment will be cut, and stock prices for pharmaceutical companies, margins for medical device firms, and bonuses at health plans will also be affected.

So, if cost control and increasing efficiency works, these lost jobs, reduced profits, and lower margins, Joe says, will hurt the economy. The economy will suffer if the health care sector is more efficient, and since healthcare is also a huge employment generator and an inefficient industry, fixing that inefficiency will reduce employment and growth.

Thus, the title of this article, “Damned if you do, damned if you don’t.”

But wait, there’s more.

Yesterday, a certain quote has been making the rounds through the media. It was uttered by Number 45. “Nobody knew health care could be so complicated.”

Yes, it is complicated and complex, but does it have to be so? If we consider the second Churchill quote above, and realize that the UK, France, Germany, Canada, and many other Western countries have some form of single payer, then one must conclude that it is only the US that has complicated and made too complex, the providing of health care to all of its citizens.

There are many reasons for this, which is beyond the scope of this article or blog, but there is one overriding reason for this complexity…GREED. Not the greed of wanting more of one thing, but the greed of profit, as one executive from an insurance company stated recently.

This brings me to the last of the articles I ran across yesterday. It was posted on LinkedIn by Dave Chase, founder of the Health Rosetta Institute. He cited a segment on the Fox News Channel’s Tucker Carlson program, in which Carlson interviewed a former hospital president who said that pricing was the main problem with the US healthcare system.

Mr. Chase does not solely rely on Carlson’s guest in his article, but cites other experts in the field as evidence that pricing failure is to blame.

If we are to except this as true, then it buttresses my point that the overriding problem is greed, for what else is the failure to control prices but a symptom of greed inherent in the American health care system, and something that does not exist elsewhere in the Western world.

Which brings me to Churchill’s first quote above. Since we Americans have tried the free market system of health care wanting, and have tried a reformed free market system, perhaps it is time to go all the way to a government-sponsored, Medicare for All, single payer system.

The bottom line is: we’re damned if we do, damned if we don’t. The question is, which is the lesser of two evils.

UPDATE: Here is Joe’s take on what will happen to the ACA in the next two years. I agree with his assessment.

ACA Repeal Opens Up Medical Travel: A Second Look

Note: Here is Laura’s second article on repeal of the ACA and its’ impact on medical travel. She breaks the article down by areas of the healthcare industry that will be affected by repeal and that might benefit from medical travel.

Repeal of Affordable Care Act Impacts International Medical Travel
by Laura Carabello

wphealthcarenews.com- The repeal of the Affordable Care Act (ACA) has been met with considerable market uncertainty. As the transition gets underway, many Americans will be scrambling to access affordable, quality care.

Fortunately, the international medical travel industry -“Travel for Treatment” – may finally gain the attention it deserves from the American public and U.S. employers. Experts predict that the number of Americans traveling abroad for medical care or episodes of treatment is expected to increase 25 percent annually over the next decade.

Medical travelers are likely to come from every market sector: the growing ranks of uninsured individuals, self-insured employers facing higher healthcare expenditures, disenfranchised Medicaid beneficiaries, as well as Medicare enrollees with high out-of-pocket expenditures and the loss of coverage for preventive care.

Individual Consumers
Once “minimum essential healthcare coverage” is no longer mandated, the burden of payment will transfer onto healthcare providers and systems that will be forced to continue cost shifting onto the backs of paying customers.

Fewer insurance companies will be willing to underwrite coverage in the exchanges. In fact, many will leave the individual marketplaces altogether because of the potential loss of federal subsidies for both beneficiaries and insurance companies themselves.

Burdened by hefty cost-shifting, more Americans will be forced to pay out of their own pockets for surgeries or treatments in the U.S. Those who can afford a plane ticket will find it increasingly attractive to travel outside the country for quality, affordable options, such as joint replacement, cardio-thoracic surgery, oncology, bariatrics, and a host of other medical procedures, including treatment for Hepatitis C.

Low-Income (Medicaid) and Seniors (Medicare)
For Medicaid beneficiaries who remained optimistic that their home state would offer expanded coverage, their prospects look dim. The unraveling of the ACA will leave millions of the poorest and sickest Americans without insurance. Many states may either abandon Medicaid expansion or be forced to significantly redesign their programs to ensure that individuals below 400 percent of the federal poverty level can receive affordable healthcare coverage and services.

While these low-income families may not have cash reserves to fund expensive care in the U.S., they might be able to gather the resources to access needed surgeries overseas – and pay less than half of the US rates. Those who have emigrated from Latin American countries, in particular, will take advantage of opportunities to travel to their homelands to gain access to care that is substantially less expensive, and in a familiar setting.

The 57 million senior citizens and disabled Americans enrolled in Medicare could also benefit from accessing international medical travel. Under a full repeal of the ACA, seniors face higher deductibles and co-payments for their Part A, which covers hospital stays, and higher premiums and deductibles for Part B, which pays for doctor visits and other services. Medicare enrollees may also lose some of their free preventative benefits, such as screenings for breast and colorectal cancer, heart disease and diabetes. The opportunity to access quality care at lower costs – plus prescription drugs that are sold at far lower price points outside the US – present attractive options.

Employers
Healthcare will continue to be driven through employers, and cost pressures will push high-deductible plans, risk-based contracting and consumerism. In the United States today, even a negotiated, discounted rate for a total knee replacement at a local hospital may well exceed $45,000, $60,000, or more. The bottom line for self-insured employers – the coverage model that now dominates the marketplace: even after factoring in the cost of travel and accommodations for the patient and the companion, as well as waiving deductibles and co-pays as incentives to program adoption, the savings on surgical procedures such as joint replacement are significant.

Employers will also be more likely to send workers to emerging COEs outside the country in light of the many partnerships that are underway between US providers and foreign hospitals. These collaborative programs are bringing American ingenuity, sophisticated technology and advanced levels of care to institutions throughout the world.

Quality and safety standards at many institutions are now equal to or exceed US benchmarks. Many foreign hospitals are accredited by Joint Commission International, an extension of the US-based Joint Commission. Select hospitals outside the country adhere to US clinical protocols.

In fact, one organization that serves self-insured employers – North American Specialty Hospital in Cancun – even offers U.S. surgeons with US malpractice insurance who perform pre- and post-operative care in the US and then travel to Cancun for surgery. This ensures continuous engagement and continuity of care.

Hospitals
The ACA has contributed to hospitals experiencing higher volumes of insured patients, but those volumes would drop with the law’s repeal. It could also cause fewer people to keep prescription coverage, which would be modestly negative for the pharmaceutical industry.

Experts believe the majority of primary care physicians are open to changes in the law but overwhelmingly oppose full repeal, according to a survey published in The New England Journal of Medicine.

Insurance coverage for the 20 million people who obtained insurance from the exchanges sparked growth in patient numbers for hospitals, which offset lower payments. Without this, hospitals can expect deepening economic problems. This could lead to higher prices, and greater impetus among individuals to seek medical care outside of the U.S.

Key Destinations for International Medical Travel
With the growing ranks of uninsured, medical travel options are likely to emerge as a critical solution to healthcare cost woes. Hospitals and providers in nearby locations such as Latin America – known as the LAC Region – are likely to become destinations of choice: less expensive travel expenses, reduced language barriers, and cultural familiarity. Individuals and employers will require guidance in terms of choosing the right providers and determining costs to overcome the challenges that lie ahead.

To view the original article, click here.

Medical Travel Impact of ACA Repeal: The View from the Medical Travel Industry

Note: Laura Carabello’s Medical Travel Today has been the best partner a writer such as myself could have in getting my idea for medical travel out to the world, and it is only fitting that I return the favor. Here is an article written by Laura on a subject I have covered many times before.

Without the Affordable Care Act Will Medical Tourism Increase?
by Laura Carabello

mdmag.com- The impending repeal of the Affordable Care Act (ACA) has created uncertainty in the US healthcare marketplace. As the existing system is dismantled, and programs shut down or replaced, many Americans will be scrambling to access truly affordable, quality care.

This phenomenon has many implications for US physicians as people in every market sector begins to explore their options – from uninsured individuals to Medicare and Medicaid beneficiaries, as well as employees covered by self-funded companies.

If the ranks of the uninsured grow as a result of the demise of the ACA, medical travel options could represent an ideal solution. According to the research published in the Annals of Internal Medicine in January 24, 2017, even after implementation of the ACA, 15% of people with chronic diseases still lacked health insurance coverage and more than a quarter of them didn’t get a checkup in 2014. About 23% of people with chronic disease went without care because they found that costs were still too high.

This signals a potential boon for the international medical travel industry, further propelling the steady growth it has experienced in recent years. Medical travel was valued at $439 billion, and is projected to grow 25% a year over the next decade. In 2016, an estimated 1.4 million Americans traveled abroad for a medical procedure.

US physicians may also find that even Medicaid beneficiaries and Medicare enrollees will be lured to hospitals and providers outside the US.

For Medicaid patients who remained optimistic that their home state would offer expanded coverage, their hopes are fading. Repeal of the ACA will leave millions of the poorest and sickest Americans without insurance. Many states may either abandon Medicaid expansion or be forced to significantly redesign their programs to ensure that individuals below 400% of the federal poverty level can receive affordable healthcare coverage and services.

While these low-income families may not have cash reserves to fund expensive care in the US, they might have the resources – or may be able to gather support from family and friends – to access affordable surgeries overseas.

As for Medicare enrollees, including 57 million senior citizens and disabled Americans, higher premiums, deductibles and cost-sharing could spark a shift toward medical travel, especially given the country’s aging population and the likelihood that many seniors will require surgery.

Seniors could face higher deductibles and co-payments for their Part A, which covers hospital stays, and higher premiums and deductibles for Part B, which pays for doctor visits and other services. Under a full repeal, Medicare enrollees may also lose some of their free preventative benefits, such as screenings for breast and colorectal cancer, heart disease and diabetes.

Self-insured employers are actively seeking to lower health-care costs and increase their financial margins, and they may opt to steer workers to more cost-effective Centers of Excellence outside their home state or region.  As a result, and despite long-term relationships with their hometown physicians, patients will be incentivized to leave the country and access care at foreign hospitals that demonstrate quality care at lower cost.  By waiving deductibles or copays – and even paying cash rewards for choosing the medical travel option – employers will prompt patients to make the decision to travel.

Further raising patients’ comfort levels regarding medical travel is the increased quality of care now offered at international hospitals. This improvement is due to the success of knowledge transfer programs and training offered by US institutions and providers to hospitals worldwide. These collaborative efforts are bringing American ingenuity, sophisticated technology, administrative simplification and advanced techniques to hospitals in Mexico and throughout the Caribbean, as well as to locations as far away as Malta and the United Arab Emirates.

If the ACA is fully repealed, distinct changes in medical travel patterns are expected.

While Americans traditionally traveled out of the country to access elective procedures — dental care, esthetic surgeries or wellness care not typically included in their health benefits packages – they are now more likely to seek reliable medical treatment for complex conditions in destinations that are cross-border but only requiring three to four hours of travel time.

Hospitals and providers in the Latin America-Caribbean Region are likely to become destinations of choice for employers, as well as individuals. The lure of less expensive and shorter travel, reduced language barriers, and more cultural familiarity are appealing to all.  The challenge will be to access benchmarks for selecting providers, ascertaining costs, determining legal recourse regarding less-than-optimal outcomes and other issues. Without the guidance of a health plan or administrator, this process may be challenging to many.

With the steady rise of medical travel, a growing number of US physicians will encounter patients seeking consultation prior to getting treatment abroad. This means providing medical records or consulting directly with the international team.

Physicians will also encounter more patients who require follow-up care after undergoing a procedure in another country. In this case, it will be important to access treatment information and discharge papers from the overseas hospital, as well as records for blood work, X-rays or other screenings for use as a roadmap for the patient’s post-care. Physicians may also be reticent to perform additional services that may be required following care performed outside the US and not in their control.

Beyond the medical details, physicians need to understand every aspect of medical travel to deal with the increased competition and cost pressures. They may want to look into making improvements and upgrading services to justify the expense of treatments here in the United States. The strongest transformation will occur in what is today the most lucrative part of the industry: high-cost surgeries and procedures. Keep in mind that US treatment costs often justify travel elsewhere, despite additional travel and accommodation costs.

Going forward, physicians can play a role in guiding patients to seek the best possible care – wherever it is available — while helping them understand the benefits and potential risks of medical travel.

To view the original article, click here.

All Quiet on the Medical Tourism Front

It’s been a while since I posted anything on medical travel, so you will forgive me for taking liberties with the title of Erich Maria Remarque’s novel about the First World War.

I guess the lull can be attributed to the shock of realizing that the current occupant of the White House is totally unfit and may be reckless, so the world is holding its collective breath to see what happens.

Or, it could be that you are waiting for the other shoe to drop, and by that, I mean, what will happen to the Affordable Care Act now that he has signed an executive order to dismantle it.

This much we do know. What we don’t know is will the Republicans in Congress repeal it completely, or will they replace parts of it. And what does you-know-who want? Canadian-style health care, as some have suggested he favors? And we also know that his nominee for Health and Human Services is against the ACA, and the Speaker of the House wants to kill Medicare and Medicaid.

Your guess is as good as mine. But whatever happens, it is certain that the industry needs to be prepared, because once people lose their coverage, they will need alternatives to high cost medical care here.

A total repeal would be catastrophic for health care in this country. Replacing it with something worse will also be bad for the health care industry, but may offer a way for medical travel to finally get a hearing with the American people, at least those who can afford to go abroad after losing their ACA coverage.

Those covered under Medicaid when their states expanded coverage will be the ones to lose the most, since they are the poorest and sickest. Those who purchased coverage through the exchanges and paid lower premiums than those who paid higher premiums, may be right for medical travel, if the industry goes after them.

Predictions are that should the ACA be repealed, premiums for everyone will go up. So, it is imperative that the industry be ready, willing, and able to handle the influx of new patients, and not just for boutique procedures and expensive treatments.

I said this once before, and I will say it again, the market will not come to you; you must go to the market. You must show Americans that there is an alternative to high cost care in the US, and for obvious reasons, only those locations within a three-hour flight will be possible.

BTW, if any of you need someone to work on a project for medical travel between the US and your country, let me know. You know me by now, so don’t be a stranger.

Healthcare CEO’s Reject Single-Payer

There are many reasons why the US is the only industrialized nation that does not have a single payer health care system.

One deep seated reason has to do with the foundational value system of the US, from the time of the early settlers whose religious convictions lined up with the rising middle class of 17th century England’s economic values (i.e., the Protestant Ethic).

But another reason — at least for the foreseeable future — as my fellow blogger, Joe Paduda wrote a while back when talking about Bernie Sanders’ plan, is that the health insurance industry will not blow up their businesses and start all over from scratch.

To prove Joe’s point, Modern Healthcare.com published an article last week that explored the opinions of healthcare CEO’s on the ACA and the subject of single-payer health care.

Here are the key takeaways from the article:

  • the nation’s top healthcare leaders overwhelmingly back the ACA
  • support its goal of pushing providers away from fee-for-service medicine and toward delivering value-based care
  • while the Republican Party and its presumptive nominee continue to stand by their “repeal and replace” slogan, the sector’s CEOs overwhelmingly reject that idea, in large part because they are unimpressed with the GOP’s attempts to articulate what it would replace it with.
  • only a small group supports moving to a single-payer system, which has been a central theme of Democratic presidential candidate Bernie Sanders
  • The overwhelming message from the survey, was that the next president and Congress should stay the course set by President Barack Obama and the ACA.
  • But healthcare leaders are also looking for the nation’s political leadership to reject complacency and look for ways to improve what they see as a far-from-perfect piece of legislation.

Here are the survey results, as published today by Don McCanne of PNHP:

The CEO Power Panel includes 110 top leaders of hospitals, insurance companies, physician groups, trade associations and other not-for-profit advocacy groups. The second-quarter survey on policy options that the next president and Congress might address attracted 86 respondents, a 78% response rate.

Future of ACA

Do you support Congress and the next president in:

Repealing and replacing the Affordable Care Act?

2.3% – Yes

67.4% – No

29.1% – It depends on the details

1.2% – No opinion

Expanding the ACA’s subsidized private insurance plan system to achieve universal coverage?

34.9% – Yes

15.1% – No

48.8% – It depends on the details

1.2% – No opinion

Scrapping private insurance in favor of expanding an enhanced Medicare to cover the entire population (single payer)?

9.3% – Yes

61.6% – No

29.1% – It depends on the details

Other insurance issues

Allowing private insurers to sell individual and family policies across state lines under national rules that preempt state rules?

52.3% – Yes

20.9% – No

24.4% – It depends on the details

2.3% – No opinion

Expanding the use of health savings accounts to pay premiums and meet costs under high-deductible plans?

74.4% – Yes

11.6% – No

12.8% – It depends on the details

1.2% – No opinion

Creating subsidized high-risk pools to cover people with preexisting conditions?

43.0% – Yes

16.3% – No

36.1% – It depends on the details

4.7% – No opinion

Medicare

Raising Medicare eligibility to age 67?

54.7% – Yes

23.3% – No

22.1% – It depends on the details

Expanding means testing within Medicare, such as higher co-pays or reduced benefits for high-income seniors?

50.0% – Yes

18.6% – No

30.2% – It depends on the details

1.2% – No opinion

Moving to a universal Medicare Advantage system with a means-tested defined contribution (premium support) for seniors?

28.2% – Yes

20.0% – No

48.2% – It depends on the details

3.5% – No opinion

Gradually expanding Medicare to cover everyone over age 55 who doesn’t have private insurance?

21.4% – Yes

48.8% – No

28.6% – It depends on the details

1.2% – No opinion

Delivery system reform

Taking aggressive measures to curb rising prescription drug prices such as allowing imports and authorizing the CMS to negotiate prices?

70.6& – Yes

9.4% – No

20.0% – It depends on the details

Repealing delivery system reforms such as value-based payment, accountable care organizations and the use of quality measures included in the Affordable Care Act?

03.5% – Yes

83.5% – No

11.8% – It depends on the details

01.2% – No opinion

So, it is apparent that as long as the health care industry continues to profit from the status quo, and supports the ACA, the likelihood of single payer will be remote at best, despite what the Sanders’ campaign seeks.

Things will only change when the entire system collapses of its own weight from complexity, waste, fraud, abuse, and excessive cost so that no CEO’s opinion will matter. People will demand a single payer system because no one will be able to afford having insurance.

The ancient Greeks, among other people, discovered the science of dialectics, or the study of change. Dialectics says that the seeds of change come from within, and that change does not happen until certain conditions are met, and change becomes inevitable. We are not yet at that point, but it is slowly moving in that direction.


 

I am willing to work with any broker, carrier, or employer interested in saving money on expensive surgeries, and to provide the best care for their injured workers or their client’s employees.

Ask me any questions you may have on how to save money on expensive surgeries under workers’ comp.

I am also looking for a partner who shares my vision of global health care for injured workers.

I am also willing to work with any health care provider, medical tourism facilitator or facility to help you take advantage of a market segment treating workers injured on the job. Workers’ compensation is going through dramatic changes, and may one day be folded into general health care. Injured workers needing surgery for compensable injuries will need to seek alternatives that provide quality medical care at lower cost to their employers. Caribbean and Latin America region preferred.

Call me for more information, next steps, or connection strategies at (561) 738-0458 or (561) 603-1685, cell. Email me at: richard_krasner@hotmail.com.

Will accept invitations to speak or attend conferences.

Connect with me on LinkedIn, check out my website, FutureComp Consulting, and follow my blog at: richardkrasner.wordpress.com.

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Low-Income Uninsured Declines Due to ACA Expansion: Kentucky

Richard’s Note: This is my 250th post, although not all of them were written by me, and some of them are just infograms; nevertheless, this is an important milestone. It shows that with dogged determination, in the face of heavy odds and criticism, one can persevere and be insightful at the same time. My only wish is that more people would read this blog, and that it would be taken more seriously. One does not need a title to be taken seriously. Just ask Donald Trump.

As reported today in Health Affairs, Kentucky, which was one of two Southern states to expand Medicaid in 2013, saw a sharp decline in the percentage of uninsured from 35 percent at the end of 2013 to 11 percent in late 2014.

This decline was part of a study that was completed before the new Kentucky governor, Matt Bevins, a Tea Party lackey, announced that he would discontinue the expansion.

The study used data from the Behavioral Risk Factor Surveillance System, an annual survey conducted by the Centers for Disease Control and Prevention. Residents of Missouri, Tennessee, and Virginia, three neighboring states not expanding Medicaid eligibility, served as study controls.

Some of the other study findings revealed declines in the number of people with unmet medical needs and lacking a regular source of health care.

But now that the new governor has discontinued the expansion, it is quite probable that rates of uninsurance will once again climb, as those who gained insurance under the ACA, will more than likely have it taken away from them.

What this means for the health care system in Kentucky, and in the other states that expanded Medicaid, should their states elect more Matt Bevins, is that people who one did not have insurance, will find themselves back in the same position before the ACA.

As I wrote back in May of last year, in my article, “Failure to Expand Medicaid Could Lead to Cost-Shift to Work Comp“, states such as Florida (my state), Texas (naturally), Virginia (legislature said no, governor wants it), Wisconsin (Scott (I hate unions) Walker, and others, are likely to see such cost-shifting.

Adding Kentucky to that mix will only make matters worse. Why the health care industry in general, and the workers’ comp industry in particular, does not explore ALL possible options to providing health care to low-income and injured workers, is beyond me.

But to leave out one particular option because some judge won’t order it (do doctors order executions?), or because some people think that medical care outside the three mile limit of the US is sub-standard, or because they like the status quo and are fooling themselves into believing that some new program or scheme will fix the problem?

And to tell your industry that those “ideas” are new trends without even trying that one particular option, cannot be called “outfront ideas”. It is just more of the same.

Readers of this blog know what that option is…it is part of the reason this blog exists, and why it will continue to exist. We must open our health care options to every conceivable possibility, no matter how far fetched or “out there” it is. It is a law of economics if you can find a product or service at lower cost, and at equal or better quality somewhere else, you will buy it. That seems to work for everything else, but health care.

 

 

 

Workers’ Comp Goes Federal: An Update

The other day, I wrote a post that said that state Medicaid programs will be able to recover all of the proceeds from a settlement that were expended on behalf of a beneficiary.

My reporting of MaryRose Reaston’s article garnered some very positive comments from some of my readers.

Yet, today, my fellow blogger Joe Paduda countered MaryRose’s article, and stated that “No, ACA has not ‘overstepped its bounds‘”.

According to Joe, the efforts by the states are just that, state-based, and they are allowed and enabled by federal legislation…separate and distinct from the ACA.

Joe cites an article written by Michael Stack, Principal of Amaxx LLC that summarizes Medicaid recovery in workers’ comp cases.

As Joe reports, Michael noted that the legislation that allows Medicaid to pursue settlements was part of the Medicare Secondary Payer Act, a part of the 2013 budget bill.

Normally, when I write about some issue someone else wrote about, I never have to provide my readers with an update that challenges the original author. Generally, my updates are just that, updates that add to the discussion. This is not the case here.

So just to be fair to everyone, I decided to correct the situation by writing a follow-up. I trust my readers will understand that I did not mean to mislead or take only one side.