If the Supreme Court Rules Against the Obama Administration …

If the Court throws out both the “individual mandate” (the rule requiring that virtually all Americans buy insurance, or pay a fine), and the provision that insurers must cover all applicants, and cannot charge higher premiums, even if a new customer has just been diagnosed with cancer?  This might sound like the end of reform, but in fact, many of the most valuable reforms in the legislation would almost certainly still stand–including those that will change the way we pay for care, reducing costs, while lifting quality. Under the Affordable Care Act (ACA), hospitals will continue to find ways to reduce preventable errors–or face financial penaltie.. Doctors who succeed in managing chronic diseases, keeping their patients out of the hospital, will receive rewards. Medical students willing to practice in underserved areas “Where No One Else Will Go” will receive scholarships, and their ranks will grow. New funding will double the capacity of Community Health Centers that can provide medical homes for many who now receive their care in an ER. Reform will go forward.

There is, of course, the possibility that the court could declare the entire Affordable Care Act unconstitutional, but this seems extraordinarily unlikely. Too many planks in the law already are being implemented, and patients are benefiting.  As Henry J. Aaron pointed out in an earlier post on this blog, overturning the law would be an “Rx for Chaos.”

Still, even if the judges “only” throw out  the mandate and the requirement that insurers cover everyone, the results will be, as former Obama administration adviser  Ezekiel Emanuel recently put it in a New York Times opinion piece “less than optimal.” (Unlike Rahm Emanuel, Zeke is known for understatement.)

Under this scenario, premiums for those who do buy insurance would climb because, without the mandate, insurers could no longer count on millions of new, healthy customers.  Instead of “the 32 million Americans predicted to gain coverage under the health insurance reform act, only around 16 million Americans would gain coverage,” observes Emanuel.

Although health reform legislation still would offer low-income and middle-income individuals subsides to help buy insurance for themselves and their  families, many healthy people who don’t  qualify for large subsidies would opt out. “This would drive up premiums by an estimated 15 to 20 percent,” Emanuel adds, “and push more healthy people out of the market, creating a downward spiral until the only people buying insurance are those who are very sick. While many states may still try to move forward with their exchanges without the mandate, they will eventually collapse.”

I agree. Keep in mind that under the Affordable Care Act, insurance companies that sell their products in the state-run Exchanges must offer “essential benefits” in all of their plans. This means insurers are required to cover benefits that are not included in many of the less costly plans that they now peddle to the public– including maternity care, and mental health services. To make up for the extra costs, insurers would be forced to raise premiums.

Instead of hiking premiums, couldn’t insurers just cut their profits? No, these days insurance companies have been losing customers, and as a result industry profit margins are slim. This is why, as I noted in part 1 of this post, both Aetna’s CEO and Ezekiel Emmanuel have predicted that the health insurance is on the brink of extinction. (Note that “profit margins”– which represent a percent of revenues that the company is able to keep– are very different from “profits” expressed in dollars. A company that reports operating profits of $500,000 on sales of $500 million might sound successful, but in fact, this means that it is spending 99 percent of what it takes in on manufacturing, marketing, payroll and other operating expenses. Its profit margin is just 1%; if this continues, it will have a hard time staying afloat. Lately, insurers have been reporting profit margins of only 2% to 4% which is why many realize that they must find a new business model.)

–An Obvious Alternative: Medicare for All.  If the private insurance industry is on the verge of collapse, many progressives ask, why not go directly to a single-payer, government run system? If the Supreme Court throws out the Affordable Care Act, wouldn’t that pave the way to the reform that many think we should have chosen in the first place? Conservatives argue that the mandate is unconstitutional because it forces them to buy a product from a for-profit private company. But we know that it is constitutional to insist that we buy health insurance from the government. We have been doing it for some 47 years. It’s called Medicare.

Moving to “Medicare for All” might seem an easy answer. But supporters face two daunting roadblocks.  The first is Congress. There simply are not the votes in Congress to pass a single-payer solution; opposition to a “government takeover” is fierce. Of course after the November election, we will see some new faces on the Hill.  But there is no way that voters will elect a majority that would endorse a government-run system. Too many Americans would be afraid of such a massive change. Over the next few years, I hope that we accept government sponsored insurance (a.k.a. a “public option”) as an alternative to private insurance.” But it will be a very long time before the majority of voters will embrace a single-payer system.

Physicians would be wary that Washington would slice their fees. Many would be adamantly opposed to working for the government.

As for patients, those with good employer-based private insurance would not want to give it up for an unknown government program. Even if private insurers close up shop, most larger companies self-insure, and their employees would continue to be covered. And the truth is that the best coverage that these employers offer, with no annual limits or lifetime limits on reimbursements, does offer better protection than Medicare. Under Medicare, when a senior hits the limit on how much Medicare will pay out, he must spend down almost all of his savings–and perhaps sell his home– before he qualifies for Medicaid. At that point he may well have to switch doctors because so many physicians will not accept Medicaid’s lower reimbursements.

I myself have a policy with no limits, no deductible and co-pays that are only slightly higher than Medicare’s ($50 when I see a specialist, rather than $35.)  If Congress did pass “Medicare for All” I would be reluctant to join unless I could afford a  private “MediGap” or “Medicare Advantage” policy that would cover the many holes in Medicare. (Even then, under many Medicare Advantage policies, I would have to shell out $35 to see a specialist, and I would face deductibles that I might not be able to afford.)  Could the government force people with generous private insurance to give up their policies? Perhaps, but it would be a bloody battle.

Meanwhile, Americans who have the best private coverage usually are relatively affluent–and healthy. If they refused to join the single-payer pool, it would be skewed toward poorer, sicker customers, and once again, we’re looking at higher premiums.

Granted, the administrative costs of a single-payer system would be lower, but as Robert Reich, who supports Medicare-for-all (or “at least a public option”)  recently pointed out on this blog, private corporations that self-insure –(and offer the most generous policies to their employees) spend only about 5-10 percent on administration, just 2 percent to 7 percent more than Medicare. Let’s assume the difference is 10%: this means that a family plan that now costs a large employer and his employees roughly $13,000 a year would cost taxpayers only $1,300 less.  Meanwhile, most of us, like most seniors, would feel we had to purchase a MediGap or Advantage policy to plug the holes; premiums for those supplemental plans would eat up most of the $1300.

— The Second Roadblock: The Cost of Medicare for All. Medicare is an extremely pricey program,  in part because, in the U.S, we pay far more for every pill and every procedure than the citizens of any other developed country, and in part, because our system is so wasteful.

Begin with hospital charges.  In Germany, the average bill for a hospital stay is just $5,004–compared to $15,734 in the U.S.  By and large, patient outcomes are just as good in Germany. That is just one example. Next, consider the cost of drugs and devices, which now account for roughly 18 percent of the nation’s medical bill. Incidental Economist’s Aaron Carroll, quoting from a McKinsey & Company study. “For name brand pharmaceuticals, we pay about 77% more. Why?  Some will say that it’s because we’re wealthier and need to subsidize for the rest of the world.  But even if we paid more based on our relative wealth, it would come to about a 30% premium, not the 77% we do pay.  Some will say that it’s because we in the US subsidize the massive research and development for drugs.  But the entire bill for R&D for the pharmaceutical industry was less than $50 billion in 2006, far less than the ‘extra’ we paid for drugs.”

Under the Affordable Care Act this could change.  If Medicare’s costs are climbing too quickly, an Independent Payment Advisory Board would be able to trim Medicare’s payments for over-priced drugs. The Board would be likely to do this if the drugs were no better for most patients than older, cheaper rivals. Following the Medicare Payment Advisory Commission’s recommendations, Medicare would cover the pricier pill only for patients who would benefit. (Congress could override the Board only it could save an equal amount of money without rationing care, or shifting costs to patients.)  Moreover, as reform unfolds, President Obama has signaled that it’s likely that Medicare will begin bargaining with Pharma, just as the Veterans’ Administration does today.

As for the “waste” in Medicare, not long ago, Dr. Donald Berwick, the former director of the Centers for Medicare and Medicaid, explained that much of the over-spending “comes from subjecting people to care that cannot possibly help them – care rooted in outmoded habits, supply-driven behaviors, and ignoring science.” Thus, patients are exposed to risk without benefit. Some die after picking up a “hospital-acquired infection” –when they didn’t need to be in the hospital in the first place.

But unfortunately, one man’s waste is another man’s income stream.  In the past, when Congress tried to cut the waste, lobbyists intervened. By contrast, under the Affordable Care Act, Medicare will have the right to use financial carrots and sticks to reduce errors and unnecessary treatments–without having to go through Congress. For instance, if a pilot program that aims at improving care while cutting costs is successful, the Secretary of Health and Human Services will be able to roll it out nationwide, without needing Congressional approval. In other words, in voting for the Act, legislators purposefully tied their own hands so that they will not be tempted to succumb to lobbyists bearing gifts.

Once these reforms (along with some those that I mentioned at the top of this post) have had a chance to kick in, Medicare should be a much stronger, more affordable program. Then, it would make sense to model a public option on Medicare. If it were affordable, and offered better, safer care, millions Americans might well choose “Medicare for All.”

Today, however, the high cost of Medicare illustrates the heart of the problem in our bloated health care system: the growing gap between the run-away cost of care in the U.S. and the resources that we, both as a nation, and as individuals, have to pay for it. Already, we are spending 16 percent of GDP on medical care, while other wealthy countries lay out only about 11 percent.  If we let the bill continue to balloon, spending on medical care will crowd out investments in other things we care about: education, jobs, public health, the environment  . . .

— The Exorbitant Cost of U.S. Care Explains Why Asking Patients To Pay At the Point of Service Wouldn’t Work.  Some observers have suggested that if the court decides that both the individual mandate and the rule that insurers must cover everyone are unconstitutional, we could just insist that uninsured patients pay for their care when they show up at an ER, a doctor’s office or a hospital. He or she would be required to pay the bill up front tapping into the money he saved by not buying insurance. This would solve the “free rider” problem.

This assumes, of course, that uninsured patients have squirreled away the money they didn’t lay out for insurance, and haven’t already spent those dollars–going out to dinner, ordering in, or just paying for the necessities: rent, utilities and groceries.

The truth is that according to the Federal Reserve, the average American family has only $3,800 in a savings account, and $117,951 in household debt. Fully 25% of all families have no savings, yet a fair number of them would not qualify either for Medicaid or government subsidies to pay for their care. They earn too much, yet not enough to foot a hospital bill. Where would they find the cash to pre-pay when they arrive at the ER?  Even if they dip into retirement savings, the typical household  has just $35,000 socked away for old age. Meanwhile, as noted, in the U.S., the typical bill for a hospital stay is $15,733– and that’s if , like most patients, you are in and out in a few days.

But couldn’t someone who decided to forego insurance refinance their home–or even sell it– if faced with a medical crisis? The typical homeowner boasts just $65,000 equity in his home, if the family is lucky enough to own a home, and it isn’t “under water.”

What would happen to a young couple who found themselves unexpectedly pregnant? Assume the new mom needs a C-section. The tab can range from $10,137 to $24,339 depending, in large part, on whether her obstetrician is affiliated with a “brand-name” hospital. Marquee hospitals have the market leverage to charge both insurers and patients more. Five percent will hit her with a bill that actually tops $24,399. U.S.  And this doesn’t include prenatal care or the pediatrician’s bills over the next six months.

–The Good News. As I suggested at the beginning of this post, it is not likely that the Justices will choose to kill the Affordable Care Act. Even if they dispose of the two provisions that are now in the spotlight, hundreds of other reforms will remain. The government subsidies for low-income and middle-income individuals will attract many young, health customers to the pool. Some have suggested that young Americans don’t buy insurance because they think they are “invincible.” But this very pragmatic generation is not that foolish.  Research reveals that 20-somethings and younger 30-somethings who can afford insurance do purchase coverage. Those who go without just don’t have the money. With subsidies, they will.

Meanwhile, other provisions in the bill will lead to safer, more efficient, and less costly care. Today “tens of thousands of Americans die because of hospital-acquired infections every year, and far more are harmed by medical errors,” notes Zeke Emanuel, who is not only a health policy expert, but an oncologist who knows what can happen, even in some of our top academic medical centers. “Last year, the Obama administration announced a $500 million program called Partnership for Patients aimed at reducing hospital-acquired infections, errors and other preventable complications” he adds. This program which was authorized by the reform legislation, “also requires Medicare to begin posting online each hospital’s rate of certain medical errors and infections, and to cut payments to hospitals with the highest rates.”

Consequently, hospitals across the country are working to reduce preventable hospital errors. Once it’s clear that this is a major priority, significant progress can be made. A few years before the health care reform act was passed, the Hospital of the University of Pennsylvania, where I work, started paying attention to reducing preventable errors, and it managed to reduce infections from intravenous lines to 1 or fewer per month from 30 to 40 per month.”

“The same goes for the problem of hospital readmissions,” Emanuel continues. “Right now, nearly 20 percent of Medicare patients who are discharged from a hospital are readmitted within 30 days. Some are scheduled readmissions; others occur for completely unrelated health problems, like falls and accidents. But many could be prevented by paying more attention to the coordination of care between physicians and hospitals and by better follow-up after patients are discharged. Beginning this year, the health care reform act will penalize hospitals that have high readmission rates for three conditions: pneumonia, heart failure and heart attacks. This list will later be expanded. As a result, all hospitals are now scrambling to figure out how to create “the perfect patient discharge” so patients don’t become hospital ‘frequent fliers.’”

Finally, thanks to the Affordable Care Act “accountable care organizations” are beginning to spring up in various parts of the nation. Groups of physicians and hospitals are banding together to deliver coordinated care at a lower cost. Under reform, they will share in the savings.

Make no mistake: all of this will take time. As I have said since the beginning, overhauling 16% of the economy will be a process, not an event. But reform will continue. We have no choice.

Maggie Mahar is an author and financial journalist who has written extensively about the American health care system. Her book, Money-Driven Medicine: The Real Reason Health Care Costs So Much, was the inspiration for the documentary, Money Driven Medicine. She is a prolific blogger, writing most recently for TIME’s Moneyland. Previously she wrote and edited the Health Beat blog for the progressive think tank, The Century Foundation. Previous work for the Health Insurance Resource Center includes Will the Supreme Court strike down health reform? She also recently provided background on Congressional health care legislation for HealthReformVotes.org, a special project of the Health Insurance Resource Center.

38 replies »

  1. Obama, is at the same time arguing that the DOMA should be considered unconstituional, while saying that unelected judges don’t have the right to consider Obamacare unconstitutional.. Go figure!

  2. Wow, I just heard that Current Occupant of the White House Barry O has decided, on his arrogant own, to declare that unelected judges cannot overturn laws, that conveniently this President decides that his own formulated ones are immune to Constitutional process. Oh, did I forget to mention this guy alleged taught Constitutional law when he worked as an alleged professor in Chicago?

    If that is not the deed heard ’round the world, I have no idea how anyone who is a true, invested American citizen can support anything this clown is behind. His comments, if not his behaviors, border on treasonous!

    Does anyone else have an opinion about this revelation? Too busy watching MSNBC news and other mainstream media falsify 911 calls to sell racism to distract the public from this constitutional matter?

  3. “That said, I shold l add, that I do believe that the sickest among us do deserve “the very best care by the very best people”,

    I would then divide the group by age:

    The sickestt children, teen-agers 20-somethings, 30 -somethings etc.
    should receive what we think is “the very best care by the very best people.”

    They have not had a chance to live a full life or see their children grow up. (”

    A 30 year old crach addict should get care before 70 year old mother teresa? Bad things happen when government decides who deserves something and who doesnt

  4. I gave much thought before replying to this above comment, Ms Mahar, so please take that in mind if you read this comment.

    you said above, “That said, I should l add, that I do believe that the sickest among us do deserve “the very best care by the very best people”,
    I would then divide the group by age:
    The sickestt children, teen-agers 20-somethings, 30 -somethings etc.
    should receive what we think is “the very best care by the very best people.”
    They have not had a chance to live a full life or see their children grow up.

    In theory, what person with compassion and concern would argue otherwise. However, making it an edict to apply this principle to everyone who fits that description is either providing false hope or just carelessly and dangerously naive to think this will impact without consequences. Treatment options are decided on a case by case basis, you don’t withhold care but you can’t tell everyone they can get the full court press without being realistic with the finite resources at hand, both per monies and treatment interventions.

    And besides that, I hope everyone reading this will really pause and reflect what I have professionally and personally seen when terminally ill people are told they should hold on. Keeping people alive longer than what is their realistic endpoint is just not fair to the patient, the family, and the health care system spending it’s time and energy prolonging the inevitable.

    PPACA is not realistic in setting that limit, at least outwardly.

  5. Actually, it was a ricochet bisquet. I meant it should have been a “wish sandwich”, where you had two slices of bread and you wish you had some meat. I am surprised no one caught that.

  6. Sometimes you have to take a stand when right trumps convenience.

    What if he dies on the operating table or just after post op? Don’t even hypothesize about physician error. I am sorry you and your husband have to deal with this situation. But, equally sorry to say it shouldn’t have had to occur. You have to ponder who doesn’t get that access as the resources are finite.

    But, I respect your honesty and candor in sharing. I hope the outcome goes well for him.

  7. Maggie, I enjoy reading your posts. I have always risen in rebuttal when the usual suspects take cheap shots at you. It’s not a bumper sticker topic. And, the issue of NHE and resource limits is not exactly news.

    The episodic rancor here is nothing compared to a lot of other sites. Price of free speech, as the proprietor noted a while back. No one’s gonna die here (though, DMD might have an aneurism).

  8. Another 5% moment Determined MD. I agree this thread has been derailed.

  9. Bobby G, John Ballard- & Determined MD . . .

    Bobby G & John Ballard–thank you for your comments.

    Determined MD–

    Thank you very much for acknowledging that the thread was derailed.

    That said, I shold l add, that I do believe that the sickest among us do deserve “the very best care by the very best people”,

    I would then divide the group by age:

    The sickestt children, teen-agers 20-somethings, 30 -somethings etc.
    should receive what we think is “the very best care by the very best people.”

    They have not had a chance to live a full life or see their children grow up. (

    Today, the wealthiest of us receive what we think is “the very best care by the very best people.” This means that we spend an inordinate amount of money on end-of-life care for relatively affluent elderly people who have both Medicare and a supplemental insurace plan (MediGap or Medicare Advantage that puts no limit on how much it will pay out in a given year, or over the course of a lifetime. The lack of limits seems to me fine– if patients benefit from the care and are able to enjoy their lives.)

    But often, elderly patients don’t benefit from unlimited care.

    Ideally they would all have access to pallaitve care specialists who would explain their options to them and their relatives, including the odds that the treatment would help them, the side effects, and all of their choices– palliative care in the hospital, going home with either hospice or pallattive care, or further hospital care, perhaps in the intensive care unit.

    ( In theory, doctors who are not palliative care specialists could do this, but most are not trained to talk to very sick patients about the possibility of dying, are not trained in managing pain, and just don’t have the time to spend the hours needed to talk to patients and relatives aobut these options.)

    Today, my husband’s 95-year-old senile uncle is undergoing a major operation.(Until a few years ago his mind was intact. He took very good care of himself throughout his life. He just lived so long that his body outlived his mind.)

    The hospital insisted on the surgery,(Medicare will pay for it),

    And my husband was not able to persuade closer relatives that this was both cruel and pointless. (How do you explain to a 92-year-old women that the surgery that the doctors say her husband “must have” won’t “save him” and will lead to needless surffering?)

    His immediate family felt that “you have to do what the hospital and the doctors say you should do,”

  10. Cue the Tin Man: “if you only had a heart”

    I guess if I was an impartial reader, I’d go to bed now too. Good job G, deflected the risk of embarrassing the argument that Ms Mahar tried to validate and risk being called on it by attentive commenters, and just made it a running side show. But, doesn’t support your alleged point of view.

    Well, see what readers will offer on Tuesday of more substantial value.

  11. You would hope as americans we want a solution that actually has a chance of working. Anything based on the false assumption that Medicare is more efficient is sure to fail. It makes a good test of what is more important, advancing a political ideology or the truth. Majority of the time the truth loses.

    Personally I find it shocking that civility is a bigger concern then honesity. It’s ok to lie as long as you do it nicely?

  12. Is denial a psychological concept or just a long river in your world? I defer readers to your tasty sandwich you are full of at the beginning of this thread. I’m on to you, let your allies have their hollow, empty laughs at your expense.

    Sorry for your earlier losses. Not sorry for your sorry derrière.

  13. I agree with accountability, Nate. But, does it benefit the authors of this blog?

  14. [1] I’m no big fan of PPACA. Long-documented. [2] I’m not a Democrat.

    I would, however, favor a mixed-model universal system.

  15. OK folks, am I clueless in interpreting Ms Mahar is a party shill, since Mr G offered the point? Maybe this site is not so impartial as led to believe. I think I have read her posts with some effort, and that is my conclusion. Mr. G on the other hand, what does he stand for?

    I think I have been pretty consistent in my writings. You, the readers, do your own conclusions. Hey, I earned the MD after my name and work hard to protect it and make sure patients appreciate it at the end of the day.

    Everyone is a doctor until accountability hits the proverbial fan. You want those shards coming at you?

  16. Nice illustration of what amounts to basic projection, sir. Explain to the masses how my criticism of lame representation is just calling names and aspersions. You’ve said to me in past threads you have no clear agenda in supporting this legislation, and yet your clear attacks are your deeds otherwise.

    I have tries to be respectful to you per your losses of late, but, I have zero tolerance of hypocrisy. I leave it to readers to take their time and efforts to review this and other threads to see if I am out of line, or, you.

    To try to resume the thead to the issue at hand, do you really want to see Democrats try to reframe the debate to justify universal health care, as designated by Democrats, or, want decisions for health handles by physicians with their patients?

  17. THCB needs a fact finding post.

    Pick an honest arbitrator then have Robert, Maggie, and who ever else make the case for Medicare Admin Fees being 2-3% compared to 5-10 or as someone else mentioned last week 20-40% and I’ll present the facts on why that is incorrect.

    If they win they can continue to base arguments on this assumption

    If I win posters would be forever forbidden from repeating that lie again on THCB.

  18. “cue-less”

    That is indeed true. I don’t play pool.

    Back on topic. Ms. Mahar wrote a detailed, thoughtful post, and you could do no better than calling her a Party shill.

    Keep digging.

  19. You live in a irony-free world. Your first comment above refutes you. You come out of the blocks calling names and casting aspersions, and then would have us take your indignation seriously when you get pushback. That dawg jus’ won’t hunt.

  20. Ms Mahar, I am sorry this thread has lost it’s way.

    Mr G, you are cue-less. God forbid you could address my question if my first comment had validity. But, your reply has done so.


  21. Can people discuss the issue raised by the author of this post, or just deflect and demean like our politicians do in DC?

    Are my points at the top so unrealistic? Or, maybe I did touch a nerve!

  22. You are so funny, do you work hard at being a jerk, or does it just come naturally? Baiting people at a site like this is just sophomoric. My original comment did not even address you in any way.

    The more you defend this fecal legislation, you give away your true colors.

    My guess, brown.

  23. It was rude, as was my reply. When do people call it as it is? Everyone is NOT entitled to the best care by the best people. Doctors like me work in different arenas to serve everyone as best a physician can with the resources available. But, as I type this, watching The Factor note that Obama’s message is the rich owe the poor.

    Didn’t sign that contract as doctor, citizen, or neighbor. Democrats can scream that assumption all they want. Per the Blues brothers, catch that in your ricochet sandwich!!!

    Sorry to reasonable readers for the above retort.

  24. “you get what you pay for, so if you don’t pay well, you don’t live well.”

    The Shit Sandwich theory of Life: The More Bread You Got, The Less Shit You Gotta Eat.

    It’s true, in general.

  25. Why is it I catch your posts just as they come up so I start this thread? Really, I had no intent to look for your post.

    2 points I have echoed over and over, so simple statements they be:’

    you get what you pay for, so if you don’t pay well, you don’t live well.

    Isn’t the Consitution written for moments like this? Maybe the 9 judges aren’t impartial and just politically motivated, and note I said all 9 are this way, but, maybe at least part of their mentality is this that you can’t get the 545 House and Senate members to agree on as a sizeable majority block: the majority of citizens don’t like this legislation, because, just maybe, more than not of the nays do know enough to see this will not solve a problem but just redirect it.

    So, aren’t the judges finding the Consitutional way of telling Congress: get off your lazy, lame asses and do your job better the next time! Striking down a law does not make it null and void to readdress! It may actually allow people who do care and are invested in representation find the way out of the wilderness.

    And that way would start in later January 2013, when the incumbents are voted out and fresh faces can do work. The election in November is NOT about the President, it is about the House and Senate. Maybe even sooner for the primaries to figure out in one party states. But, I think Ms Mahar does not want to entertain that perspective, because it is not about what is best for her party.

    Party, that is one term that does NOT fit for Political groups! Just Mob Madness!!!