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The Healing American Healthcare Podcast
The Healing American Healthcare Podcast

Episode 19 · 1 year ago

A Public Option for American Citizens

ABOUT THIS EPISODE

As a legislative strategy for a public health insurance option is starting to form in Congress, Ed Eichhorn and Dr. Tom Bellavia go over the questions posed in the discussion and what needs to be considered going forward. 

Music: 

"The Discovery" 

by The Lemming Shepards 

Exzel Music Publishing (freemusicpublicdomain.com) 

Licensed under Creative Commons: By Attribution 3.0 

http://creativecommons.org/licenses/by/3.0/  

Well, thank you for joining us today. Today we're going to discuss and effort by Democrats in both chambers of the House and Senate to launch a public option. This is being led by the Senate health, education, Labor and pension's chair, Patty Murray, a Democrat from Washington, and the House Energy and Commerce Chair, Congressman Frank Polone Junior, a Democrat from New Jersey, and in a recent article that appeared in roll call, they're asking for support with a request for information to help decide on their legislative strategy. There are eight questions that they are asking in this request for information. The first question is who should be eligible for coverage through a public option? How should the benefits be structured? How should prices for healthcare items and services be set? How could congress ensure that people enrolled in a public plan have adequate access to providers? What type of premium assistance should be available under a potential plan? What roles states should have in administering a federally run option? How might it interact with Medicare and Medicaid, and how could a public option address other healthcare objectives like delivery system updates and reducing health and equities. We're discussing this today with Dr Tom Belivia, who's been with us several times in the past to discuss important issues and healthcare. Dr Belli via is a product of the New York City school system and graduated from New York University's Washington Square college with a Bachelor's in biology. He immediately entered the University of Rome Medical School and did his postgraduate training in medicine at the Hackensack University Medical Center. After serving in the United States army medical core in Texas and Virginia, where he reached the rank of major and also was chief of professional services at Kenter Army hospital, he returned to the attending staff at Hackensack University Medical Center. Dr Bellavia has been an advisor to both the state of New Jersey and federal governments on healthcare issues and was recently invited to serve as the chair of the New Jersey Department of Health and Senior Services Task Force on chronic kidney disease. He is board certified in Family Medicine and Correctional Medicine. He's a senior attending at the Department of family practice. Attending at the Department of Medicine and associate professor at the University of Medicine and Dentistry of New Jersey. Dr Bellavia is a member of the board of Trustees of the New Jersey Academy of Family Practice and its foundation, the New Jersey Academy of Family Physicians and the Amer an Academy of Family Physicians. He is chairman of Austar Health, providing HIPPOC compliant health information technology...

...and application integration services for fit positions, hospitals, patients and insurance providers. He is active in many additional organizations with philanthropic missions. Dr Bellavia began his practice of family medicine in Woodridge and subsequently created heights medical associates in Hasprooke Heights, where he still sees patients every day. Well, I want to thank you for joining me today, Dr Bell A via. Today we'd like to discuss a new legislative effort that's been introduced in both the Senate and the house by the chairman of the Senate health, education and Labor and Pensions Committee, Senator Patti Murray, and Congressman Frank Polone, who's chair of the Energy and Commerce Committee, and they're interested in exploring the issues around setting up a public option legislatively, and in an article that recently appeared in roll call they asked for request for information and they listed eight areas that they like to get responses on to help them to formulate their legislative activity. So I wanted to ask you what you thought about these eight questions and if you're ready to begin, I'll ask you the questions. Okay, if I may just make a comment about healthcare before we go on. Today, when I was reviewing these questions here about this public option in Medicare for all and so on, it just brings to mind that I think the public should understand why the federal government is trying so hard to provide quality healthcare at a much cheaper price than possible, because the course of fealth care in the United States is probably better than twenty percent of the GDP and couses a lot of havoc downstream on everything the country does. The one thing that I recall president trump saying about health care was who knew that health care was so complicated, and this area of Medicare for all and public option is just another attempt to try and resolve these issues of health care and provieting quality health care across the country. All these, in my opinions, so far that the federal government has tried to do have not been very successful. Throughout the last several years, the CMS and Medicare especially, have tried various freimbursement programs in the attempt to get to triple aim of, you know, better quality and lower cost and patient satisfaction, and it in the fourth aim of a physician provider satisfaction, which have been unsuccessful. The amount of money saved and the amount of quality that has been produced by the federal government these programs has been where I consider a rounding error, and we now know that the United States quality of care is about thirty seven to four in the world, which is not a very good place debate the amount of money that's spent to just leads me to believe that there's too many special interest in healthcare that are trying to make things work, too many bureaucrats in it and so on. So all these attempts are difficult and nobody's really set...

...down to have some comments sense attitude to this and that saw us both the patients, legislators positions and the public. But now referring to Medicare for all and for public option, which another two attempts to resolve the problem, which I'm not so sure that they will be successful either. One in my opinion, medicare for all and whatever it is, is just going to be too closely for the American government to sustain without some input of dollars. And you can't provide healthcare to people on a small amount of money in today's world. It's the same problem that we have in the Medicare multiplace where the states promise selfcare to the indigent people, but the health care that they get, based on the amount of money allotted for it, is poor and ill and not very good in anybody's sense. The unfortunate things that politicians don't want to face up to that reality. And I'm sure there is not enough money to take care of all there. So it is a terrible problem. So any attempt at it I welcome, whether it's Medicare for all or public option to be decided. So the issue here is, you know, there's some people going to want public option. We're not going to make everybody happy, that's for sure. So some may one medicare for all, some may want us to single payer system. Some maybe want private insurance and so on, and it is too complicated to try to fit them all into one place. But as far as these things are concerned, if you're going to give health care, it has to be structured correctly. I think everybody has to have a stake in it. Patients have to stake then as well. That means they have to be much more compliant and understanding why these programs are coming forth. So these two programs, share of the public option and so on. Who's going to use them? Of course, anybody in different positions, every patients and individual every families, different there right as a different financial status. So what does the government really want to provide to these people? What has to be covered? So if you're an obstetrition or your young female going to have babies, you want to make sure that all be taking care of. Female care is taking care of. P actus is well taken care of. All in injections and immunizations have taken care of at little and no cost. So it is a very difficult product to answer these questions like this, and I think the senator and the congressman are asking the questions very intelligently, because these are serious questions to be answered. So who should be eligible for the courage in public option? It's going to be a public option. Everybody should be cut right. If it's better gift for all, then everybody has to be covered. How you going to segment them out? What are you going to what are you going to carve out? I know and doing value basic care, we try to carve out, for instance, certain cancers or transplant medicine because the so high cost and can't be done in the value based model, because they're so close that nobody's going to be successful at it. How the advantages to be structured? Again, that's got to take a lot of thought and freedom out that, though. It actually of how it's got to be structured, how it could be working. We all know that all these government programs,...

...no matter what they are, are fraught with danger and difficulty in going through them. The regulations that are posed upon the healthcare industry to get to these things, are anyments? Are they going to eliminate all these things that? Are you going to make it easier to do or they're going to take away the barriers? And when they structure is I think a lot of those issues have to be considered here. And how should the prices for health guidance and SERAS BE SET? Well, the government has that already. They have a rock. They have a situation in which they set the prices or they correct. Probably not, and you'll have arguments all along the health industry on those reimbursements, on the valuable at all. And then we have the issue of the cost of the conglomeration of hospitals in this country who demand high prices because they answered to their stockholders. We don't have really too many not for profit hospitals anymore. These conglomerates and not not for profit. They only think about the bottom line. So how are we going to set these prices? I remember the state of Maryland. I think that no matter what Hospool you went to in Maryland, whether it was John Hopkins or poked on Hospitl in some town Maryland, the pressures were the same. You know. Look, that is still going on, I know, and that's been written about quite a bit lately as a starting point on the issue of pricing in hospitals to expand to other states. But they've been doing that since two thousand fourty. So this is such a political football okay, and my feeling is is that when he gets to healthcare, politicians are afraid to act. They are afraid of what the public is going to do. If they public thanks for any one minute that a politician is going to take away healthcare from them in any sense of the way, they're dead in the water. So we have to overcome the fear of politicians and bureaucatch in this issue and health care, because we won't go forward at all. As as as just mentioned, this has been for a lifetime. It's been my entire lifetime in medicine, in my entire lifetime in medicine, when you have hospitals buying physicians who now have to obey the laws and regulations of their bosses and the stockholders and no longer care and be compassionate and caring for the patients, but following the doctrines of the corporation, which demands that they have referrals to only to themselves because it's a bottom line dollar amount. When you have that going on and you gradicated the independent positions in the country, the patients in this country are never going to get a fair share at good quality medicine. Why did youse these hospital groups to all the advertiser you can't go through a day. Would have an at least twenty ever advertisement see the radio or TV for all these hospital groups. You can tell me that every single hospital group has the best cancer care to country. Everybody has used news and World Report. I don't even know if they pay for that at like. The issue is is they have to advertise because they can't get out the quality of care on a face to face, mouth to mouth referrals from one person to another, which should be the standing in healthcare. So to try and answer these questions here for Senator Maury and...

Times be prolonged. They're difficult. So what role the states have? An administrators? How successful have been have they been? And then ministry in the medicate situation, which is in both a possible of fifty percent thing between the station and the federal government. That hasn't worked out very well at all. They are completely at odds and it varies all over the country and it buries all over the country. So how are you going to get a national policy when all the states have different policies going on? And, let's face it, the administration of Medicare, I think, is about three percent in taking care of this, where the private insurance is about fifteen percent. Why is that different? You know where is the difference? That is it because the private insurances have to pay stockhold this and dividends. Why are we transformed? Some of this enormous amount of money and advertising across the country and healthcare, and let's put it into actually healthcare delivered. Let's take the six million dollar president of the hospital system salary and make it more reasonable and take some of that money or the entire hierarchy of hospitals that has an awfuload of executives and costs and turn that money into healthcare. Why don't they consider giving it in the state of New Jersey, I think in this stone, hold me to the truth here, but we are very near the bottom in reimbursing the doctors here. We just in any federal system. Okay, I think we get reimburse here in New Jersey, lest in Alabama, or Mr Sipping for that matter. Okay, and this is reasons for that as well, but all these issues have to be fixed before you really get a good public option and it has to be cheerfully throught out and has to be thought out without malice and prejudice, and I don't know if we can get that between politicians and bureaucrats and somebody to do that. So although they try, and and I reckon and I to mend the Congressmen and the and the senator trying to do this, but you know, how is this delivery system, for instance, going to reduce health to equis? Why haven't they done that? That would all the programs they've had here. They've had the programs on the CMS, they have a program between the states and federal government. How come they came six these and equalts? The reason is that the course of healthcare is enormous and out of control and every time you try to put a situation in where you want to reduce the course and to are still giving good quality, it fails because of special interest and I would say that one of the special interest is the conglomoration of hostel system supposed the country who become me too's to health plans and whatever they they demand in price they have to give and otherwise they can't be in the system of that health plan to attract patients which would be customers to them, or the physicians bad matter. So trying to get a public option. It's the same problem over and over again. This is a Ditto of what's going on in the past. The same questions that should have been answered to the health care industry a long time ago, and until they're...

...really willing to do this, it's going to be a problem. We're going to go down the same street. The question the answer to these questions are going to be. You already have these questions answered. They're all over the federal government. They've done this ten times or it. It's the same thing. How long have they been trying to fix the erupt at the federal level, which is the reimbursement? Why wasn't that work? Well, wasn't working because there was in equities in representation amongst physicians. There was no primary care physicians had any say in the RUCKT. So people who did procedures got a lot of money and people who use their brains to get people under control get very little mine. And you know, if you're going to buy a quality product, unfortunately, you got to pay for it or put programs in place that make it happen. And there are problems that can be done to make it happen and I think that one of the things that it's cases a problem the healthcare industry is everybody's left the patient out of the equation. Nobody has allowed the patient to be able to handle the money that's necessary to take care of them. was to give them enough to do it. And it's been known for a long time that the federal govern doesn't think that individual Americans have enough intelligence to know what to do. But about buying health insurance or buying the quality of care that deserves? The employee thing, so only the employee the size, what kind of health claim? Why do we include the patients in the three legged school so that we can get a good health care system? Okay. Why do we bring back a little bit of competition in the healthcare system? Okay. Why don't we get doctors in my town here fast books? If there are three doctors here and has vertites and we get into a health plan, we're all going to get the same reimbursement for what we do. That doesn't mean we're all equal. That doesn't mean they were all equal in quality, that doesn't mean we're all equal. And from passion to patients, but if you had the dollars in the patient's hands and he's willing to pay two dollars more out of his money to get good quality care at a physician that has good reputation for experience and giving good quality care. Bring back competition. Competition makes everybody healthy. Competition makes everybody better. In every physician that I find my practice, I've considered him better than myself as positions. I don't want to get somebody that's done with me. I want always somebody that's smarter than me in health care to bring my patients the quality of care I think they deserve. I want to do it in a very efficient manner, but government does not let that happen and going into public option will medicare from all but just propagating the same nonsense in the healthcare industry. I'm sorry at that answer some of the questions. It doesn't, but I think these are crucial. The answer all these questions that they're investing these questions are out there. All the answers to this is that what type of premium? Yeah, and those way use. I think you know. I think you're right about the issues being out there. When I look at this request for...

...information for public option, I think of it as something to compete with private insurance, not something to replace it. Petition is actually that's what I'm saying. PUT It out there compete with the private insurance companies. Also, it needs to be done in a way. You know, I just completed a healthcare survey that I put out online and forty percent of the people who responded wanted to keep the health insurance that they had because they were satisfied with it. And Fine, they should be able to keep it, you know, and unions that have negotiating healthcare systems and have gotten a particular plan approved, you ought to be able to keep that because they worked hard for that. But I think a public option might be a way to simplify. Obama are a little bit. And you heard that the three quote up acas money right, yes, yes, they did. You know, I think taking the ACA off the perverbial plate would have been extremely difficult anyway. That would have a replacement. Yeah, so I'm glad that the Supreme Court turned down the ruling that came out of access. That said, it should the whole law should go away unless you can replace it with something that's worth while. Even though it may not be the best in the world, at least they have something and I got to tell you that, in professionally speaking, I got to tell you how many people don't go for healthcare because of ACA, because of the high deductibles? Sure they just ly into the public yeah, well, we give me this an insurance, but if you make it that the patient has to put out the first five thousand dollars, it's worthless to them. Yeah, well, there was an extension is I'm sure you're familiar with during the last four years, of temporary insurance that could be sold for three month period to a full year, and the example that was given was a female between twenty and twenty five would pay four and ninety five a month for the coverage. It did not include maternity benefits and the deductible was ten grands. So why spend the twenty five months at all? Exactly, it's exactly my point. There's no logical thinking that the beaurecrets have done in the development of health care delivery, the politicians of our country of put the head in the sand, you know, thinking that by giving them medic gage or something like this, is really given them healthcare. It's not given them health care at all. And besides, the thing that they do they pay less and they make it harder to give the patients care. It's red us. It's actually and my feeling is that politicians do not want to face the reality of what health care is really a bad well, you know, the other issue we with respected difficulty for politicians is the health care providers that live in their district. If you want to control the price of pharmaceuticals and you have a pharmaceutical plant in your district, it's unlikely that you're going to want to support reducing the price for pharmaceuticals because of your representation of your district. So I think this is a very challenging problem. And also, you know, there is a confluence of lobbyists called a partnership for America's healthcare future. It includes...

...several lobbying organizations and certainly if something came into committee on public option, they would be there explaining why a public option really wasn't the best thing, quote for America, from the perspective of the pharmaceutical companies and the hospital AH A and other organizations that are are part of that partnership to lobby for keeping things the way they are. Well, I think that you know healthcare is, you very complicate situation, too many special interest groups involved in it. I think the public has to can become much more educated about healthcare and what's all about. I don't mean you just a delivery and what pills you got to take it despite best patients, but I think as purchases of health care in this country and the government should put together a program which it tends to people don't have the money and helps everybody. That doesn't mean that has to be one system for all, but has to be an even playing field for everybody to get into the system. If a Medicaid patient should get the same access to care as somebody has a goal premium private insurance, they should have the same and that's what the government should strive for. But you can't impose that. Okay, you have to really think about how you want to give those people that and you have to take a care of the pricing structure the country. What does it really co us? That's educate patients as well as there's health care that is needed versus help to that is wanted. So you know, you may want an MRI, but you needed them right. Okay, so patients, they they bumped. They got to paint a day. The first thing they wanted in Mra of they need he's gonna be quiet that. But look at what you put the physician in. Oh, you don't want to give it to me, I'll go to the doctor down the street. Well, that's that's the push advertising. You know, the pharmasy industry spends twenty five billion dollars a year and advertise to the farmer cuticles that they want you to prescribe, so that patient comes in and says I want this or I want that because they saw it on TV right exactly. So you know, there's a lot of education has to go on. You have to start at the base all these problems. Yet I just see Medicare for all and public option and maybe something to start what, as you said, getting least get your feet away. But it brought with the same danger of unsuccess as every other thing that's gone on in the pest M and we have and learned all lessons. Yet we haven't learned all lessons of health care and to me sometimes I think it's that people do really more afraid to put their hands around. I think you're right. I think it's complicated and I think it's not something that the general public really wants to spend their time thinking about and they haven't been driven to become consumers of health care. You know. Yeah, so we can educate them to be good consumers of health care, it would change the whole system with the bad. Right now, as an experience,...

I can tell you that there's a page on a stretcher and an emergency room. He doesn't care what it costs, right and what it cost just save me, right, and I think that's why politicians are worried about that. No matter what changes they make, even though the system maybe bad, it's going to fullbe if because that guy of stretches going to say, are you trying to take away what I may have? And that's the issue, you know. That's why, historically there's so much uncompensated care that occurs in the system because, you know, people are not covered, they have a serious health condition, they end up on that stretcher, they get treated because they have to be treated, they should be treated, but there's nobody going to pay for that. And I'll give you a little story. Okay, I don't know how many years ago I was the chairman of the Medicaid Tomitty of the Medical Society of New Jersey. Okay, the medicate population wouldn't go to private physicians will for the first part, and private physicians really didn't want them to come because the amount they would get paid for a visit. When I first started that was seven dollars. Of its seven. He's got increase if the fifteen years to fourteen dollars. Yea. The federal government in the State of New Jersey, for instance, didn't care if these same patients went to an emergency room, fake care with the minimum amount, of course, for that patient, was a hundred nine dollars. Does it take a lot of intuition to fix that problem? Right, I would say so. Let's say you increase the reimbursement to doctors to thirty just example. I mean doctor was say, okay, maybe enough for me to open my doors, I don't lose any money, I'll take care of and the government was save a hundred nine dollars of this. It went nowhere. Politicians would completely deaf to the idea to believe death. You mean you doctors, the fat catch all. You want to lose increase your income. I know I'm want to be able to care for these people, not on my dyme, because I'm not the one that's supposed to be taking care of you. The state are supposed to be taking care of these in the Jim People, not me. Personal again, it was a very, very hard fight, very very hard fight. I give another example. Well, I was there. I got New Jersey state government to increase health care to to the medicate population by fifteen million dollars, seven point five million dollars a year, one to primary care physicians and then seven point five million dollars would be added in the second year to include specialists. After the first year they killed it and took away the money. So that left a very bad taste of physicians mouth. We can't trust the government either. So there's a lot of experiences out here that people are living with and I think that we've got to get to the patients. I think we have to build an army of patients and get them educated as to what...

...health care is really about and where the money is flowing to and why the indigen people are being promised healthcare when they really not getting health care. The question is, how do you activate this population to do that? And as I say that it's very, very complicated. Well, it is I mean, you know, most of the stories I hear where people are concerned are people who've had a bad financial experience with health care of fost there's a quote in my book from an anonymous patient to had a heart disease and she said thank God for my physicians and my surgeons who saved my life, but the bills are going to kill me. And you know she had that of two hundredzero bucks. You know, biggest region for the bankruptcy in America today is healthcare. Course, absolutely sixty two percent of bankruptcies every year are for health care and you know, anybody who's going to answer that question will try to fix it. There's nobody's coming forward. Where is our government? Where is our government in this day Ereld Hospital conarmates to wet to help this thing? It's all special interests. So I think if we in getting program out there that educates the patient population, then maybe get something done. But right now we're we're dead with with the with the special interest groups, lobbies. Give me another example. You've heard of the DNA testing in position medicine. Right, yes, wait, you can predict disease is coming forth. You know, few years ago they came out with a test of doing the DNA test to find out if this drug would work better in a eyecorn or myself. And we could do that test and in a class of hypertensive eyes of the ISH. We know which would work best with your DNA and therefore describe a more appropriate medication. Feel precision medicine, personalized medicine. Right the form of lobby killed that test. Why is that? Because now the acceptable I do that DNA test on you, maybe their product is no longer my preference for you. So they killed it across the board. I understand now that there is some some people trying to get that back because it's a good quality care. The same thing with drugs like warfering. It may not work for you, it because you are DNA. So we're spending a lot of money in the farm suitable industry, which maybe for not, but the Farms who industry doesn't want to fix that say, fought that test and it's not on the market anymore. The lobbyists killed it and then they made it not unsurable at a cost of a thousand dollars a test. Well, that'll take it off the market. That takes it off the boy so there's so many instances in and I don't believe in in that one instance makes the difference of how the policies go follow. Okay, you can't just go by one instance, but the issue is is that healthcare is complicated and I don't see any government agency, Senator, House of representative person actually trying to do well, maybe they're...

...trying to do what's right, but they're just blind study that was really going on. I also think what the senator and the Congressm are trying to do as moderates is they're trying to move forward with something that is really a first step. I understand the answers to the question. Is that posing already already out there? No, I you and I are on the same page, Dr Bell Bee. There's no question that a lot of what they're asking for is is readily available to them and they just ask the right person for the answer to the question. But I think it's important for us to talk about these issues because we want our listeners, people who are interested in healthcare, to understand that this is a difficult issue and facing this issue is important for our country. As you know, it's CMS does a projection every year about the future of healthcare costs and they project now within the next five years health care will be twenty five percent of our economy. There is no doubt in my mind. There's absolutely note that in my mind that that showed it may not, it may be too low. Yeah, Oh, yeah, maybe, want it could be. So what I did is so you just to know. Yes, lest week or ten days ago, I sent a letter to several members of Congress, potent Senate, then the house, asking them to reform the National Physicians Council for Healthcare Policy, but proposed to the way it was in the past, or was multi specialty doctors across the country. I asked them to make it strictly amongst primary care positions. And the reason I did that is this. We know for a fact to the document study which is done several years ago, that every state in the union the head of preponderance of primary care versus specialist had two things, better quality and lower costs. And those states that had a high componderance of specialist in a low upon the primary care physitions was completely opposite. And that's how the State of New Jersey's ninety percent specialist, ten percent primary and we're at of a boxing costs and those states that at least half and half or predominantly primary, because the entrance into the healthcare system is done by the primary care position, and they can lead to parade of trying to reduce plussed. Okay, because we all know, and I'm at saying this against my colleagues and especially field, but their job is to propagate their income. Again, what's necessary, what's wanted? Okay, so there are a lot of problems there, but I think that one of the things would be is to have a national physicians canceled of primary positions, with the knowledge that primary care is the leader in health get to at least a quality cost and also to get something in the winds of educating the patient population. That's just my it's just my thoughts, but I don't see a lot of those things happening in the very near future. Maybe through these podcasting getting out to the public, maybe can you get some...

...interest going amongst people? Well, hopefully we can help people learn about the complexity of a change in health care and the need for the change in health care. You know, in our book killing American health care that we were owed a couple of years ago, we believe we have a very competitive health care system and still reduce the cost of it by thirty percent. And if we were good caused by thirty percent, primarily on hospitals, insurance companies and pharmaceutical companies, we would still be the most expensive healthcare system in the world. We be a little bit more expensive than Switzerland, which has a two part system. About forty percent of their people are in a public plan and sixty percent or in private health insurance. In that country. Health can unite. Station is a sad thing right now. It's a sad state of affairs and I wish that our government really step to the plate and it was really necessary to help the American public and healthcare, because without health care and without health where we going to be? Well, I believe health care should be a foundation for everyone in absolutely around you need to have a solid foundation that you can rely on in case you need it. Now, you know there are people that go through lives very healthy and live a long life and never require healthcare, but the other ninety eight percent of US need healthcare and we ought to get it when we need it and not be concerned about the cost of it when we go to get it back and they should least be afforded preventive kit. Sure. I mean that is the gateway to a longer life expectancy is preventive care, you know, and the fact that you know our nation suffers from a larger B city problem on diagnosed type to diabetes, among many other maladies. Absolutely, there's don't doubt about it. Know that I'm sorry I didn't answer you the question specifically. It's okay, but that these that these points of view, if anybody trying to help the healthcare system had to hear some of these issues that I that I brought up to make it right. Well, I appreciate that and you know, I look forward to our next conversation and now that we've had this discussion about things that are very difficult and very complex, I hope the rest of your day is a good day and thanks so much for joining us once of Youaid. Thank you for the opportunity any time. Take Care,.

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