Until now, non-health care business has been noticeably absent from the health care reform proceedings , and quiet about the bills’ impacts on their management of employee benefits, on cost, and on the larger issues of global competitiveness. Where have the voices been of the powerful business leaders who will pick up much of the tab?
They’ve finally surfaced, and now we’ll see whether they have the will to bring reform back on track. They certainly have the strength. The question is whether this salvo by the business mainstream could force Democrats to reconsider and revise the content and structure of their proposals.
On October 29th, a powerful collaborative of major employer organizations sent a letter to Speaker Pelosi and Republican Leader Boehner asserting that the House legislation “falls short of the bipartisan goal of controlling costs and jeopardizes employer-sponsored coverage which now serves more than 160 million Americans.” The same group sent a similar letter to Senate President Reid earlier that week.
It is important to note that the collaborative – the group includes the American Benefits Council, the Corporate Health Care Coalition, the ERISA Industry Committee, the U.S. Chamber of Commerce, the National Association of Manufacturers, the National Association of Wholesaler-Distributors, the National Coalition on Benefits, the National Retail Federation, the Retail Industry Leaders Association, the Business Roundtable and the National Business Group on Health – represents the mainstream of American business. In general, these associations’ member firms have sponsored employee health coverage for decades, and understand the linkages between health, productivity, cost and competitiveness. Their very real stake in the outcome, their long term sponsorship and their sheer collective clout enable them to enter and change the terms of the discussion.
Then, Tuesday, Employee Benefit News published a list of 10 specific items prepared by National Business Group on Health President Helen Darling, a longstanding progressive voice in health benefits, that “should concern plan sponsors that provide health care benefits to their workers.” The bill, she said:
- Lacks meaningful ways to control health care costs;
- Takes us down the road to even worse deficits and crushing national debt by not getting more savings from the health system and making the coverage more affordable;
- Does not support strong evidence-based medicine or a way to make certain that we don’t pay for treatments that are not effective;
- Does not establish a strong independent Commission that could help Congress make the politically hard, but obvious, good decisions to eliminate wasteful and harmful treatments and spending;
- Does nothing to correct medical liability problems and related costly defensive medical practices;
- Doesn’t expand employers’ ability to help employees to actively engage in wellness activities or achieve health goals;
- Undermines ERISA and opens ERISA plans to unacceptable burdens;
- Raises serious questions about the public plan and how it would operate;
- Could require an employer who provides comprehensive benefits to still be subject to an 8% payroll tax if employees decline employer coverage because it costs more 12% of the employee’s income; and
- Contains an outrageous requirement that would require employers still offering retiree medical coverage to continue it indefinitely, thereby hurting employers who have maintained retiree benefits in good faith.
Non-health care businesses comprise about six-sevenths of the economy – meaning they have six times the heft and influence of the health care industry – and financially sponsor coverage for more than half of Americans. Year after year, employers have borne the lion’s share of onerous health care cost increases, 4 times general inflation over the last decade. Endless reports have described how health care, business’ largest and most unpredictable benefit cost, has sapped America’s global competitiveness and placed its employers at a severe disadvantage. An equal torrent of words has been spent on health care’s excessive waste, at least 30% of our $2.6 trillion expenditure, or north of $800 billion annually. Even so, most business leaders are loathe to simply give up the health system they currently sponsor, its flaws notwithstanding, unless they can be confident the alternative can result in lower cost, improved quality, and an equally or more productive workforce.
Keep in mind that, at this point, health care reform has been a series of power plays between Congress and the health care industry (meaning the professionals, firms and associations representing health care’s four major sectors: the supply chain, HIT, care delivery and insurance/finance).
Until now, the health care industry – those who seek dollars – has dominated, lobbying Congress and contributing enormous sums to election campaign coffers to make sure that the legislation doesn’t impede health care profiteering and sends new funds their way. Meanwhile it has held its breath, apparently hoping that other interests with clout won’t notice. As the bills come down to the wire, the air waves have NOT burned with cautionary and righteously indignant health care industry messages opposing them. That’s because organizations in the health industry are reasonably certain they’ve won. They have been sitting tight until the deals are done.
And with good reason. As they stand now, the reform bills are very generous to the health care industry, facilitating, through mandate and/or subsidy, millions of new customers but, as we’ve recently pointed out, doing pathetically little to rectify the health care crisis’ structural drivers. For example, the health plan sector can raise rates without restraint, and a significant chunk of Medicare dollars will be transferred to private sector control. The biotech industry gets a 12 year moratorium on generic competition. With only token progress away from fee-for-service reimbursement and toward primary care re-empowerment, the system will continue to make specialist excesses lucrative. The American Medical Association (AMA) and Medical Group Management Association (MGMA) couldn’t be more enthusiastic, though both are now campaigning for H.R. 3961, which would eliminate the 21.2% drop in Medicare physician reimbursements scheduled to go into effect January 1, 2010. There are many more examples.
Commercial purchasers have waited to see how all this would play out. But now they’re stirring, and not a moment too soon. Non-health care business leaders finally appear to be mobilizing against the weak cost control provisions of the current proposals.
What is needed now is an orchestrated, mobilized, highly visible campaign effort that features the faces and voices of well-known American CEOs, and that leverages the full force of business’ leadership across industries, not just for their own interests, but for those of all Americans. The places to start are in the structural areas we and others have recently discussed: primary care, fee-for-service reimbursement and cost/quality performance transparency. Properly implemented, reforms in these approaches throughout health care could have profoundly positive impacts on both cost and quality, empowering the market to make health care far more affordable for businesses and working families.
It is possible that the entire health care reform process just changed tone and direction. If it did not, then we’re no worse off than before. But if it did, then the ramifications for how American policy works – not just for health care but for all our issues – could have just entered a new and profoundly important paradigm.
Brian Klepper and David C. Kibbe write together on health care market dynamics, health IT, innovation and policy.
“I never understood the lack of coverage for long term care like nursing homes, or that insane doughnut hole.”
Margalit – To provide long term care as part of Medicare would be prohibitively expensive. LTC is basically custodial care mostly for the frail elderly who can no longer perform some or all of the normal activities of daily living (ADL’s). Medicaid alone already spends more than $100 billion annually for LTC for the poor and billions more for home healthcare. If it were suddenly covered by Medicare, people would come out of the woodwork by the hundreds of thousands to claim benefits that are currently being provided by family members, albeit often at considerable financial and emotional sacrifice. It’s just not affordable to cover it. My wife and I purchased long term care insurance about eight years ago. The daily benefit started at $150 and includes inflation protection. We pay a bit less than $3,600 per year for a policy to cover both of us for life after we pay out of pocket for several months first. Most people cannot afford that.
The Part D donut hole is the result of politics. Lawmakers wanted to keep the 10 year cost to $400 billion but they wanted to sprinkle benefits over as many seniors as possible in order to maximize the number of elderly voters who perceived Part D as a “good value” relative to premiums paid. They could have easily designed a benefit with a higher initial deductible of, say, $500 or $600 instead of $250 and there would have been no need for the donut hole. However, that wouldn’t have satisfied their political objectives.
Regarding special interests, economists tell us that the single biggest thing we could do to bend the medical cost growth curve would be to eliminate the tax preference for employer health benefits and lower income and, perhaps, payroll taxes instead so the Treasury doesn’t collect any more net revenue than it does now. The biggest opponent of this idea: labor unions, a key Democratic constituency. Sensible tort reform that took medical disputes out of the hands of juries in favor of health costs could, over time, significantly reduce defensive medicine. The biggest opponent: trial lawyers, a key Democratic constituency. Instead of just bashing insurers, drug companies and other corporate interests, the left would enhance its health reform credibility if it were prepared to take on its own special interests. I won’t hold my breath waiting.
Finally, those of us who staunchly oppose a public insurance option do so, in part, because we think the government simply cannot be trusted to sustain true level playing field competition with private insurers even if it starts out that way. Nate’s comments regarding the history of Medicare suggest that such lack of trust is well founded.
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Barry, you’re a lucid & thoughtful contributor here. While you’re on a roll, why not explain for Margalit the reasons why “illness” is a matter frequently poorly suited for insurance in the 1st place, whether the “insurer” is the government or a private entity? Surely you’d agree that anyone who has spent any time in the health insurance business and has had to endure various bodies’ credentialing/continuing ed requirements has a grasp of those principles. Further, it’s an issue the public would benefit from understanding more thoroughly.
Be sure to include plenty of examples featuring behavioral health, back pain, etc cases.
Nate, you should join in, too. Your “history of the Medicare fraud perpetrated by Congress in 1965″ was comedy gold. Keep that stuff coming!
“I would be the first one to admit that Medicare is a mess.”
Margailt would you also admit Medicare is not what the people wanted and Congress lied to the public about what it would do and what it would cost? You made some strong claims that government should be trusted, you don’t understand why people don’t trust it and it only gives the people what the majority want….I disproved all that and you glossed over it and moved on. You held some presumptions that were very wrong, do you still beleive as you did when you typed that stuff or do you know understand the distrust?
Nate,
This is not as simple as government is/is not to be trusted. Government is not a monolithic, static entity. It is composed of people, with different beliefs and different levels of integrity and mental capacity at different times. I’m not sure that it makes sense to debate whether we do or do not trust government in general. In theory, we should trust the notion of democratic governance. Reality is that some governments have been more trustworthy than others.
I am not trying to evade the issue at hand, and I do understand the distrust. If you scroll a billion comments back, you will see that I am not at all happy with the way government functions right now either.
The main difference between us, I think, is that your solution is to eliminate government intervention, so we are on our own and may the best man win. I think governments are very valuable social tools and we should work towards ensuring trustworthy governments, even if we disagree with the currently elected flavor, and this goes much beyond just health care reform.
incohate,
I totally agree that illness does not lend itself very well to “insurance”, hence my contention that health care should be a social service, financed by taxation and administered as such.
Margalit, what do you define as illness? Health care should be a social service, indeed, but who is going to define health care? Needs or wants? Should I be taxed to pay for your invitro fertilzation? We can’t provide all things to all people, we can’t afford to. Already there’s a backlash to the evidence mammographies are over-used.
Lisa,
Is it shortsightedness or deliberate obfuscation when people ask about paying for other people’s health care?
Are you OK paying for my 12 children’s education even if you have no kids?
Are you OK paying for my food stamps? Should you pay for Russian caviar as part of my food stamps? How about fresh salmon steaks?
Are you OK paying for maintenance of Yellowstone park even though you never go camping?
Are you OK paying beef subsidies while being vegan?
Are you OK paying for my Medicaid care?
How about foster care for all those 12 children when I decide to change my diet to alcohol and coke exclusively?
Are you OK paying for my bus to work even if you own three cars? How about paying for interstate highways if you never left the county you were born in?
Are you OK with paying part of the brand new baseball park downtown even if you never watched a game in your life?
Are you OK paying to help hurricane victims even if you will never experience one yourself?
Are you OK paying for executions even if you think they are nothing but government sponsored murder?
My definition of illness is the human condition.
First, let’s make up our mind regarding the principle. Are we a socially responsible society whose success is measured by the collective well being of all it’s members, or are we a collection of isolated individuals measuring personal success only? Are we a forest or are we a bunch of trees?
So make a decision, either way. We can quibble about the details later.
Margalit, basic education is a social need and crucial to the evolution of all of society. I have no problem contributing to your 12 children’s primary education. You can buy whatever you want with your food stamps, they don’t go that far if you want to blow it all on Russian caviar that’s up to you. In your examples, there are LIMITS. If Yellowstone blows their entire budget covering one lodge in 24k gold plating, but the rest of the park becomes a polluted cesspool, society would make some changes. I’d rathar pay for executions than pay to feed and house convicted murders for life. So yes indeed, let’s make up our mind regarding principle. To quote MLK, morality can’t be legislated but behavior can be regulated. “The human condition” we can’t afford to provide all things to all people, Margalit.
The human race isn’t on the verge of extinction. Society doesn’t benefit if I pay for your IVF.
Margalit,
I would like to address the issue of lack of trust in government as it relates to healthcare. Nate, in past posts, spoke of the history of Medicare, Medicaid, public housing, public education and other government programs that either did not live up to their promise or cost far more than initially projected or both.
Historically, when the left proposes programs like these, they tell us that their motive is a fairer and more just society and they claim the moral high ground based primarily on their noble intentions and supposed concern for the less fortunate. The problem, from my perspective, is that when programs don’t work like inner city public education and public housing, the left never admits failure. Instead, they claim we need “more resources.” We commit more resources and we get more failure and higher taxes and/or larger deficits to cover the bill. They also underestimate the extent to which individuals will game the system to claim benefits, usually by hiding income so they can minimize or eliminate tax payments while qualifying for subsidies and other benefits to which they are not legitimately entitled. I’m reminded of a quote that I think is attributed to the writer, James Joyce. He said: “The force of idealism is lost when it fails to recognize the reality of things.” Good intentions alone won’t get the job done.
Two large sectors of our economy that have seen costs increase well in excess of general inflation for decades now are healthcare and education. In both cases, government plays an outsized role as both a payer and a regulator. The current direction of health reform would give the federal government and even larger role than it has now. In light of its record across a wide range of entitlement programs, more government involvement is likely to make matters worse, not better. This is especially true, I believe, with respect to the so-called public insurance option. At the same time, the status quo is unsustainable and unacceptable.
So, what’s my alternative you may fairly ask? If it were up to me, I think the following reforms would go a long way toward righting the system:
1. Eliminate the tax preference for employer provided health insurance and raise salaries by the amount employers are currently paying for health insurance. Reduce income and/or payroll tax rates sufficiently to ensure that the federal government does not collect any more in taxes than it does now. The standard deduction and Earned Income Tax Credit (EITC) could also be raised to protect the working poor.
2. Reform the medical tort system. Replace juries with special health courts with the expertise to resolve medical disputes objectively and fairly. Provide doctors and hospitals with safe harbor protection from lawsuits if they follow established evidence based care guidelines.
3. Take steps to root out fraud more aggressively. Any doctor or other provider who has the power and authority to perform or order a service, test or procedure and bill a payer for it should have a biometric ID card that includes a picture and a unique numerical identifier.
4. Increase the use of living wills and advance directives and establish registries so the information is available to doctors and hospitals when needed. This should cut down on futile and often unwanted end of life care.
5. Invest in electronic medical records to reduce duplicate testing and adverse drug interactions, especially in hospitals.
6. Move away from the fee for service payment model toward bundled payments and partial or full capitation to the extent feasible.
7. Develop robust, user friendly price and quality transparency tools to help referring doctors send patients to the most cost-effective providers.
8. Encourage the use of high deductible insurance that would pay all costs for covered services once the (high) deductible is satisfied.
Over time, I’m confident that these strategies could bend the medical cost growth curve significantly without a public insurance option and without smothering the insurance industry in overregulation. If we can, in fact, bend the cost curve, we can much more easily afford to provide subsidies to lower income people to help them purchase health insurance.
Barry,
The problem with health care costs is that there are objective factors outside the control of either government or private industry that push costs up. I am not at all convinced that the main reason for cost escalation is the fact that government is involved in regulation.
I do agree that good intentions are never enough and should be tempered by reality, but I also believe that good intentions should be the starting point in all endeavors.
I think almost everything you listed up there is fairly common sense. I do take exception with high deductible plans, since the difference in premiums between those and the regular plans is, in my experience, not that large and the net effect is that folks just take more risk and ultimately pay more for health care, while insurers pay less. I don’t think the public can absorb any further increases in health care expenditure. If a $5000 deductible plan would have $5000 lower premium, that would work, but that is not the case.
Everyone is so damn afraid to chip in a little more so that the rest of the country can be healthier. It’s not socialism. It’s democracy. It’s called sharing. We learned it when we were in preschool. It’s time we put our basic rules of morality into practice. This may not be a perfect bill, but it’s an improvement. If you’ve got something better, naysayers, let’s see it.
I commend this excellent review of the failure of HR 3962 and the Senate plan to be economically sustainable. Nancy Sebelius’ optimistic estimate of the cost of health care in 2020 is 23.3% of the GNP versus 23.2% with the status quo. Helen Darling’s 10 salient cost issues are well taken. Klepper and Kibbe are right that the place to begin is “primary care, fee-for-service reimbursement and cost/quality performance transparency.”
Consider “Physician Managed Care”, an imperfect health care reform plan but better than the Democrats’ efforts: http://doctormanagedcare.com/PMC/Book.pdf
Physician Managed Care will describe a new comprehensive plan that promises to shift up to $10 trillion over 10 years in medical system waste to valuable health services for patients. Patient care would be administered through competing private “accountable care organizations” (ACOs), with patient health risk adjusted global budgets. Patients would choose their ACOs and change if they are unsatisfied. Primary care physicians (PCPs) would coordinate all care, offering additional services such as same day appointments, 24-hour phone consultations, and non-urgent questions answered by email (i.e., similar to how “direct practice” PCPs now operate). ACOs could consist of local networks of physicians (PCPs and specialists), groups of PCPs, or fully integrated health systems (i.e., HMOs like Kaiser Permanente and the Mayo Clinic). ACO health care professionals would provide care to members, or the ACO would contract for patient services as needed with independent specialists, hospitals, and other health services providers.
Physician Managed Care funding would be from both the federal government (73%) and individuals (27%)—patient premiums ($200 per month per adult and $50 per month per child) and out-of-pocket payments for uncovered tests and treatments. Low income people would receive subsidies for premiums.
With Physician Managed Care after 2011, all increases in health care spending would be in the private component of costs (i.e., insurance premiums, out-of-pocket spending, and charitable giving). The federal government contribution would remain frozen at the 2011 level ($1.7 trillion). Assuming that free market forces driving efficiency eliminate inflation in private costs, the percentage of the GDP would be back in line with that of developed countries all over the world by 2020 (12.6%,). Even with a 10% per year increase in private health care spending, national health expenditures would remain at the current level of about 18.0%. Compared with the status quo national health expenditure projections or the Democrats’ HR 3962 plan, Physician Managed Care would save the country $4 – $10 trillion by 2020. Consider this proposed method of bending the health care inflation curve in relationship to the projected $9+ trillion federal deficit by 2019.
I am amazed that we don’t see costs being contained through these reforms. The federal and state governments will lower their rates,patients will continue to have free care in the emergency room,insurers will not give hospital higher rates. Cost shifting has stopped at the door of hospitals. They will close,merge or more likely change into primary care centers,wellness centers,free standing asu,medical homes,retail clinics. This radical change was the intent of health care reform.Insurers and pharmaceutical companies will pay a little bit more into the system but will survive and grow. Hospitals have attempted to push back on how health care should be delivered through lobbyists and politicians. The Trojan horse has entered through reform and now it is time to adapt.
Hospital Cost shifting is what targets patients and leaves them vulnerable for unsubstantiated Expenses that are intended to make up for the uninsured. The Facts are that Health Care has priced themselves out of a fair Market value. Ever increasingly setting themselves up for failure or Non- Payment for services.They are just Too expensive and Health Insurance contracts are not paying there fair share.Insurance Manipulates and inflates the Cost of Services and often leave not only the individual but the institutions saddled with excessive Debt.
Its unbelievable that Providers would allow Insurance to dictate to their Members. Its embarrassing that providers would sign a non Competition Clause that virtually enslaves them to the whims of insurance. Counter productive clauses such as these only limit and constrain Improvements.
Contractual agreements such as these Superficially Drive up Cost, employ wasteful duplication, and unnecessary procedures. Can We do better? Yes! However it will take a miracle to change minds of those who are comfortable with the Status Quo.
we all know we need more Competition. nobody is making this point. lets try the free stuff first. its free. if it doesnt work then we can change our stratagy as needed. my idea is to get the consumer in the game. lets say i need an mri and the insurance companys and the goverment will pay 1200 dollars. if we offered the consumer a rebate of half the amount we can save back to the consumer they will call around and find the best price. people will all the sudden care what it cost and try to find the best deal. it will force hospitals to post prices or hire more staff to take all the phone calls. so lets say i found one for 600.00 the goverment would save 300 dollars and i would make 300. its a win win. goverment saves money and i make money.
Employers provide insurance in a effort to recruit New Employees and compete with other Business’s. They select policies based on Premium Dollars and functionality. Recently my insurance company raised premiums 30 %. The choice for the employer was either accept the increase in premiums or increase from $500.per person to $1,000.00 per person deductibles and the cost of emergency room Visits from $100.00 to $250.00 among other changes. This is a Business decision based on the law of averages. Business decisions often clash with personal Needs.
I have read some of the post above and I can tell you that employers continue to pass on the majority of the expense to the Employee. They are setting on the sidelines because they don’t want to upset the broker who offers insurance and for some ,it is the cost of Doing Business.
I have seen young opinionated individuals claim to know it all about Health Care. What they know won’t fill a recipe card.The problem is we have spoiled our children to the degree of being selfish,uncaring,and mutually self absorbed to understand the problems or the plight of neighbors and friends that are denied Health Insurance.More importantly they don’t care and they feel that it is their duty to block change. This Behavior is destructive and needs to be changed. Spare the rod;spoil the child.
A journey of a thousand miles begins with one step. Let’s talk about the first step. This first step should address healthcare cost which is pushing us over the edge. Why has the concept of state Medical Public Service Commissions (PSC’s) not surfaced? We have seen in areas where there is a competition problem that PSC’s can do a good job. Let’s turn the problem of healthcare costs over to state PSC’s.
In so doing there are numerous hidden benefits that you would not expect at first blush as follows:
1. PSC’s will determine the basic cost of each Medical Charge Code used by providers to bill insurance. If the current medical charge code manual is not specific enough for some procedures, new medical charge codes can be added to help narrow these costs. Then these determined costs will be adjusted for inflation annually until reviewed again and a new cost basis set. In addition, the PSC will calculate a market adjusted mark-up percent for fair and reasonable provider profits for the coming year. The provider mark-up percentage will be determined by a new market ‘check and balance ‘ mechanism unavailable until now. More on this later.
2. Because some Zip Codes have inherently higher costs than rural areas, the co-pays may vary by Zip Codes to offset these cost differentials so the Medical Charge Code cost basis can be leveled across the state. These office visit co-pays would be standard across all insurers in a Zip Code and paid by the patient. These co-pays should not deter patients from seeing their doctor.
3. The PSC eliminates provider networks and provider service contracts. Thus, competition between providers is increased because insurance no longer delivers a pool of patients. Patients can go anywhere in the state and use their insurance because all insurers pay the same for identical services as set by the PSC.
4. Insurers now compete solely on the price of their policies because the doctors/hospitals are no longer tied to their networks. All insurance is accepted by the doctors/hospitals because they all pay the same PSC rates.
5. The elected State Insurance Commissioner may increase insurer competition quickly, if needed, by soliciting outside insurers to come into the state and compete. There are no network or provider service contract requirements.
6. The PSC can greatly reduce the over prescribing of medical services by the way the provider mark-up (profit) percentage is determined. It can tie the profitability of the providers to the profitability of the insurers. If the profitability of the insurers decline because of the overuse of medical services, then the mark-up percentage for the providers is reduced on every Medical Charge Code. The providers will then think twice about how they prescribe healthcare because it now directly affects their profits. This one feature alone will cut healthcare costs significantly.
7. Tying the provider mark-up to the net profit margins that private insurers earn in the state creates a healthy ‘check and balance ‘ mechanism. If provider costs go up, profits of both go down. If profits go up above what the average state business earns, the State Insurance Commissioner can intervene and license new outside insurers to compete and lower premiums, if necessary. But both the insurers and providers have a right to earn a reasonable profit, so the elected State Insurance Commissioner will only increase insurer competition when it becomes necessary to reduce average insurer profits for the benefit of the public when these profits noticeably exceed what other state businesses earn.
Note: If insurer profits surge due to the more efficient delivery of healthcare, then the insurer can invoke a mechanism to reduce gross profits with offsetting insurance policy premium reductions. This results in a lower net profit for the insurers which the PSC will use to determine the provider mark-up percentage for the coming year. Thus by lowering premiums, the insurer gains a direct cost reduction for the coming year from a lower provider mark-up percentage. This allows the insurers and providers to earn fair and reasonable profits and policyholders to pay lower premiums. If the insurer refuses to lower excessive gross profits, then the State Insurance Commissioner may intervene and policyholders may react by dropping the insurer for a new one during the end-of -year sign-up period while retaining their same doctors/hospitals.
8. The PSC does not make healthcare decisions and does not affect the doctor-patient relationship. The full time job of the state Medical PSC is determining the cost of Medical Charge Codes. The PSC will standardize these codes to make filing claims easier for doctors/hospitals.
The state Medical PSC concept has amazing potential. Not only does it break the bond between doctors/hospitals and insurance companies, but it relies on a ‘check and balance ‘ system to spread the wealth among providers, insurers and policyholders. Without a doubt, this approach has never been seen before and will position the American Healthcare system to control costs as healthcare is expanded by Washington. Congress does not know about this brilliant idea. Please write/call your representatives and tell them that we must have state Medical PSC’s.
Nice article, thanks for the information.