The Business of Health Care

Monopoly Anyone? The Battle To Control Health Care

Like children gathered around a card table, America’s special interests are engaged in a high stakes game of Monopoly. But the winner of this game gets more than a day or two of bragging rights; this time the spoils are nothing less than control of our health care delivery system for the foreseeable future.

Let’s meet the players: on one side, Big Medicine; across the table, Big Insurance; and between them, Big Government. There’s room at the table for a 4th player…but we’ll get to that later.

Introducing Big Medicine

To compete in this high-stakes game, Big Medicine is reforming itself into large, multi-disciplinary organizations. Independent hospitals are merging into hospital systems. Hospitals and doctors are coming together as self-regulating Accountable Care Organizations (ACOs).

Big Medicine’s path to victory relies on persuasion: “Who knows more about health than the professionals? Then who better to manage healthcare delivery? Government regulation and insurance carrier interference are unnecessary and actually counter-productive, so their argument goes.

But this is the very same thinking that got us into this mess in the first place. Before managed care burst on the scene 40 years ago, 40 percent of American women were undergoing hysterectomies but less than one in ten of those procedures was medically necessary. Medical self-management gave us the spiraling healthcare costs and mediocre quality of care that we are trying to fix today.

Meet Big Insurance

Perhaps Big Insurance would be a more worthy winner. After all, back in the late 80s and early 90s, it was the insurance industry that put the brakes on Medicine’s reckless over-treatment (and over-billing) of patients.

Unlike Big Medicine, the insurance industry is not relying on persuasion to win this game: its weapon of choice is economic clout. The giant, double-digit rate increases of the past two years have put this player in a catbird’s seat.

Insurance carriers are already administering government money through the Medicare Advantage Program and they are likely to dominate the government-sponsored health care exchanges mandated by last year’s health care reform legislation.

But letting insurance carriers manage care is just another old idea in new clothing. As much as medicine failed to self-regulate, regulation by bean counters proved no better. The unconscionable rationing of care by 1990’s HMOs spurred a popular revolt that culminated in the Oscar winning film, As Good as it Gets.

Hello Big Government

Last, but by no means least, comes Big Government. This player may be gobbling up more properties these days than the other two players combined. Not only have we passed health care reform legislation on the federal level, but there are similar reform initiatives percolating in nearly every state. Hawaii already has a single-payer system and Vermont may not be far behind.

Under health care reform, government forces companies to offer benefits, requires individuals to buy benefits, defines how benefit plans are designed and stipulates what benefits they deliver. In the coming years, a steadily increasing percentage of pre-retirement Americans will be dependent on government subsidies for their health benefits; and by 2014, every state will have a government mandated insurance exchange. It’s a good time to be Big Government.

To win this game, Big Government is not content just to use its power to legislate, tax and enforce. Government is also working to choke off the other players’ oxygen supply. Doctors’ fees are to be cut. Insurers’ margins are to be capped. Once cash strapped, these two players may drop out of the game and forfeit their properties…to Big Government.

It is hard to love any of the players at this Monopoly board.

Presenting the Patient

But wait! One side of the table is still empty. There is room for another player. “How about the consumer? After all, it is the plan member who gets sick (or doesn’t) and who gets well again (or doesn’t). Consumers want access, they want quality and they want value. A win by the consumer would be a win for everyone. Surely, this player should have a seat at the table.

But alas, this is still one more idea that has been tried and found wanting. The Consumer Directed Health Care (CDHC) movement of the last decade showed promise, but in the end, consumers were not powerful enough to stand up to the machinations of the other players. Medicine refused to grant consumers the transparency needed for value-based decision making; Insurance turned CDHC into a massive cost-shifting scheme and Government is working feverishly to stifle consumer choice by forcing everyone into cookie-cutter plan designs.

The Player of the Hour

Despite its ultimate failure, Consumer Directed Health Care was a step in the right direction. Unfortunately, the individual plan member was not strong enough to stand up to the behemoths in the room. Consumerism could still work but the consumer needs a more powerful advocate!

Who could represent the plan member at the table? The private sector employer! The employer’s interests are perfectly aligned with the member’s. The employer wants its plan members to be healthy and wants to achieve that in the most efficient way. After all, employers still pick up most of the tab for working Americans’ healthcare and the employer suffers the greatest economic harm when an employee is absent from work or works unproductively due to poor health. Only the employer has incentive to make sure employees have access to the best possible care at the best possible price…and the economic clout to make it happen!

So where is the employer? Why isn’t the employer at the table already? Over the past decade, the employer community has endured a withering assault from Big Government and Big Insurance. And it’s taken its toll. So much so that today’s conventional wisdom holds that the era of employment-based health benefits is coming to an end. The truth is that the percentage of working Americans who enjoy employment-based health benefits has declined slightly in recent years.

But is it any wonder? The policies of Big Medicine, Big Insurance and Big Government have driven the price of conventional health insurance beyond the reach of many small employers. At the same time, these same players have systematically sabotaged the employer community’s efforts to control cost through creative benefit funding strategies.

For example: states continually impose additional expensive benefit mandates and last year the federal government joined the pig pile with Mental Health Parity. Those states with some version of health care reform have limited the range of plan designs available to employers and if federal health care reform takes effect in 2014 as planned, virtually all opportunity for plan design creativity will disappear.

Surprisingly though, Big Government is not the biggest culprit here; it’s Big Insurance. A few years back, many employers began to take control of their benefit budgets by buying high deductible, low premium insurance policies and making up the difference with Gap Plans, Wrap Plans, Health Reimbursement Arrangements (HRA’s) and Health Savings Accounts (HSA’s.) The result was richer benefits for plan members and lower costs for plan sponsors.

But this strategy also resulted in less premium income for the insurance carriers and Big Insurance struck back. Carriers began refusing to issue policies to companies unless they promised to rely exclusively (or at least primarily) on traditional insurance to fund their employees’ health benefits. The use of creative funding strategies has been severely curtailed.

As a result, employers now have just two choices: buy a high cost, cookie cutter plan from an insurance carrier or buy a lower cost plan and shift claims cost onto plan members. Economics has forced many employers to choose the latter option and the resulting redistribution of cost has further fueled cries that the employer-based system is broken.

And broken it is. But broken by design, not necessity.

Big Medicine, Big Insurance and Big Government offer three different paths to the same disastrous destination: uncontrolled inflation followed by severe rationing of care. Big Bang followed by Big Crunch. And in the end, we will be left with nothing that resembles the health care universe we know today.

A Way Forward

The only way to escape this increasingly inevitable fate is to empower the consumer through the agency of the employer. The employer, and only the employer, is in a position to deliver wellness information and services to plan members and to represent those members’ interests in the political and economic arena. Here are a few additional recommendations:
.

  • Insurance carriers must cease their efforts to limit employer- sponsored benefit supplements.  Government needs to eliminate all restrictions on employers’ plan design creativity.
  • Anti-trust laws need to be relaxed to allow companies to share data and cooperate in joint wellness and quality-of-care programs.
  • And hospitals and medical practices need to cooperate with employer-based quality-of-care initiatives and suspend any policies that discriminate against non-traditional claims payers in favor of large insurance carriers.

If we can achieve consensus on just these few policy changes, we will be well on our way to restoring the centrality of the employer in the health benefit process and we may then yet hope to see our game of Monopoly end happily…with no monopoly at all!

David Cowles is a founding Partner and the current Executive Vice-President of Benemax, an innovative benefit management firm in Mefield, MA. He is primarily responsible for new product development.

This post first appeared at Health Affairs Blog on 09/06/2011. Copyright ©2010Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

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Merle BushkinMD as HELLJohn BallardDavidDeterminedMD Recent comment authors
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DeterminedMD
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DeterminedMD

You know what Nate, your comment above, “They wouldn’t need PR nor to worry about bad press if people weren’t taking shots at them for political gain. The employer did nothing wring nor anything heartless. They did what they had to do to run their business.”, is about as pure capitalistic and devoid of heart and concern as it comes to prove my point why profit has no place in health care. And I do not expect you to say anything else but more of the same from your replies. I respect you do not want PPACA to succeed, but… Read more »

nate ogden
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nate ogden

“California, which already pays Medi-Cal providers less than all but two states, also is pushing to cut payments to doctors, hospitals and others who serve Medi-Cal patients by 10%. That would drop reimbursement for a standard physician visit to less than $12.”

In doctors defence how do you make a profit off a $12 office visit, no wonder they have no clue what profit is.

Merle Bushkin
Guest

Determined, Let’s be clear on accounting terminology. Assuming you account for your practice on a cash basis, what’s left from revenue, after deducting operating expenses (including rent, salaries, wages, etc. and your draw), is profit. What you do with this profit is up to you. You can withdraw it, reinvest it in your practice, pay off loans, or distribute it as dividends. Whatever you do, it NEVER is operating costs. What is important to understand, is that without profits, you cannot do any of these things and your practice will rapidly collapse. Many doctors are in this situation today. They… Read more »

Margalit Gur-Arie
Guest

My conclusion from this thread is that John Ballard is a very smart person.

There seems to be a genuine misunderstanding of the difference between profit and compensation. I don’t know what else to say…..

John Ballard
Guest

Thanks, Margalit.
As I said, he/they really don’t get it.

Merle Bushkin
Guest

Determined and Margalit, You are two smart people but, for the life of me I can’t understand your inability to grasp the importance of running medical practices, hospitals and healthcare services, in general, in a business-like manner. I’m not suggesting that business people decide the forms of treatment or care patients receive. But I am saying that healthcare cannot prosper unless its institutions are run in a business-like way. They simply must take in more than they pay out or they will fail! We can’t afford to continue our system as is. It will bankrupt our country! And the solution… Read more »

BobbyG
Guest

Yeah, apropos of that , see

“Medical Practices Work on Ways to Serve Patients and Bottom Line”

http://www.nytimes.com/2011/09/08/business/smallbusiness/medical-practices-keep-eye-on-the-business-side.html?pagewanted=print

Also, in the NY Times, see

‘Adjusting, More M.D.’s Add M.B.A.”

Google it. I have the link, but if i add it I’ll get “moderated.”

DeterminedMD
Guest
DeterminedMD

Here is your poster child for why there is never a place for profit in health care: http://www.myfoxphilly.com/dpp/news/local_news/lawyer-explains-how-donor-was-fired-091311 And I link the story how a lawyer defends why the company had legitimate rights to fire the woman. For spending time with her terminally ill mother, then donating a kidney to her son. Ok, if it comes out the woman lied and used the most disgusting false excuses to get out of work, then fine, she deserves to be fired. But, not reading that anywhere thus far. And I am glad to see a lawyer defend this disgusting mind set of… Read more »

nate ogden
Guest
nate ogden

Are you suggesting the company should just go out of business instead so everyone loses their job? How is a small business suppose to hold a position if they have no one else to do the work?

Give a praticle answer to how this sitution should have been handled.

DeterminedMD
Guest
DeterminedMD

I expected someone else to reply, but since you ask Nate, and I came back rather foolishly looking for mayhem to be in the thread, I’ll be the hypocrite and answer: First of all, maybe FMLA needs to be redefined, so it wouldn’t put companies at risk for long stays out of work. Second of all, how many employees out of work legitimately as compared to the total work force would define the risk of company failure. And third, isn’t PR with handling of employee matters somewhat of a boost to a company when people hear the management, wait for… Read more »

nate ogden
Guest
nate ogden

“maybe FMLA needs to be redefined, so it wouldn’t put companies at risk for long stays out of work.”

It doesn’t need redefined its already defined so that companies to small to absorb an employee out on extended leave do not need to comply with the law.

They wouldn’t need PR nor to worry about bad press if people weren’t taking shots at them for political gain. The employer did nothing wring nor anything heartless. They did what they had to do to run their business.

John Ballard
Guest

FMLA was adopted in 1993 during Clinton’s first term. Prior to that no such protection existed. The legislation, as the cited article says, does not apply to small companies. I’m not aware of any companies that have gone out of business as the result of being in compliance with FMLA. Then, as now, our two parties were divided along the same lines, with Republicans mostly opposed and Democrats in favor of the new legislation. http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=103&session=1&vote=00011 http://clerk.house.gov/evs/1993/roll022.xml The outcome of the case was completely legal. The employer was legally in the right but not necessarily right in the compassionate sense of… Read more »

nate ogden
Guest
nate ogden

“I’m not aware of any companies that have gone out of business as the result of being in compliance with FMLA.”

Wouldn’t that be becuase small companies that can not afford to comply with it are not required to? Like or dislike the law as written it is workable for business. You can argue could a 45 life company comply, maybe, but does anyone out there think a 3 employee company could comply? In some states you can’t fire the replacement just becuase the person on FMLA came back.

Merle Bushkin
Guest

Determined and Margalit, You are two smart people but, for the life of me I can’t understand your inability to grasp the importance of running medical practices, hospitals and healthcare services, in general, in a business-like manner. I’m not suggesting that business people decide the forms of treatment or care patients receive. But I am saying that healthcare cannot prosper unless its institutions are run in a business-like way. They simply must take in more than they pay out or they will fail! We can’t afford to continue our system as is. It will bankrupt our country! And the solution… Read more »

John Ballard
Guest

I knew you’d love it, Nate. I was thinking especially of you.

nate ogden
Guest
nate ogden

it’s typical Maggie quality work, what’s not to love. Another shining example of what happens when people that don’t understand healthcare pontificate and legislate healthcare. It will be the first of many errors proven that she made but the savings in Appendix A have already been discredited by live data. The OTC change actually increased cost. Instead of people paying for their OTC items post tax like the bill envisioned they have ran to their doctor in hordes to get prescriptions for OTC items. Not only has the tax savings not been realized but now we are wasting money on… Read more »

John Ballard
Guest

Special link. Hot off the press.
35 Pages (pdf)
Just because I love everyone here.

The Congressional Budget Office has concluded that the Affordable Care Act (ACA), signed into law by President Barack Obama in the spring of 2010, will more than pay for itself, provide coverage for 32 million uninsured Americans, and trim federal budget deficits by some $210 billion over the ten years ending in 2021. In this issue brief, Maggie Mahar synthesizes the relevant numbers and offers in-depth analysis of exactly how the ACA will both strengthen health insurance protections and save money.

http://tcf.org/publications/2011/9/better-care-for-less-how-the-affordable-care-act-pays-for-itself-and-cuts-the-deficit

nate ogden
Guest
nate ogden

Is that the same CBO required by law to score bills as told by the politician trying to sell it? i.e. if ObamaCare claims Leprechauns are going to visit every time there is a rainbow and leave behind $100 billion to be applied to the cost of the bill CBO must score it as such. In fact when was the last time CBO got an estimate right, or to be fair to CBO when was the last time a bill scored as legally required was correct? Its not CBOs fault the politicians tying to pass legislation mack a mockery of… Read more »

nate ogden
Guest
nate ogden

http://thehill.com/blogs/healthwatch/medicare/178751-state-officials-say-cbo-may-be-overstating-healthcare-savings

State insurance regulators might challenge an estimate from the Congressional Budget Office (CBO) that they fear is giving the supercommitee an inflated view of certain healthcare savings.

Margalit Gur-Arie
Guest

You can probably have a decent profit driven agenda that provides most people with mostly good health care, most of the time.
While this is lovely for selling whole wheat cereal and laptop computers, it is not an acceptable model for health care, because it is neither sound nor responsible, not to mention ethical.

nate ogden
Guest
nate ogden

Margalit what do you think happens when you remove the profit motive, do you think there are no negative effects. Access to care drops. New innovation drops. Why would a doctor open an extended hour clinic in a rural community if he can’t make a profit. They don’t open the clinic, the community has less access, and care suffers.

You ignore all the positive drivers of profit.

DeterminedMD
Guest
DeterminedMD

Your rebuttal is Physicians for National Health Program? They would not want a profit oriented system in place either, but, I once was a member and they are not grounded in the realities of the logistics of implementing National Health Care in America. Nice try though.

BobbyG
Guest

“Rebuttal”? Wasn’t intended a rebuttal, just an inferential observation.

What, precisely, is YOUR vision for the health care space. Or you simply chronically angry at everything and with everyone?

Merle Bushkin
Guest

Those of you arguing the merits of profits in medicine might be interested in two articles from the NY Times last week, both of which relate to the need for doctors to understand how to run a business:

http://www.nytimes.com/2011/09/06/business/doctors-discover-the-benefits-of-business-school.html?_r=1&ref=health

http://www.nytimes.com/2011/09/08/business/smallbusiness/medical-practices-keep-eye-on-the-business-side.html?pagewanted=2&ref=health

It also would help if you were familiar with Generally Accepted Accounting Principles (GAAP accounting) — not to become accountants but, rather, to be able to intelligently discuss the simple concepts of costs and profits.

DeterminedMD
Guest
DeterminedMD

What, so we can master principles from a sole business point of view? I have talked to people with a strong business backround who are grounded and realistic, and they basically say what I have said, business priniciples cannot be applied to the dynamics of health care. Face it, you cannot have a profit driven agenda and provide sound, responsible health care. They are eventually incongruent. Again, explain the point of capitated care before it was rejected back in the 1990’s. Hmm, maybe it is all those dead bodies who suffered from this heartless agenda the defenders are stumbling over… Read more »

BobbyG
Guest

“Face it, you cannot have a profit driven agenda and provide sound, responsible health care.”
___

http://www.pnhp.org/

DeterminedMD
Guest
DeterminedMD

Some people just think their twisted interpretations and expectations are the gospel and to be revered. It’s the basis of narcissism and having the world view through a pin whole.

And they think they are cute and protected from consequences or challenges just because they don’t use names, just those dumbass hyphenated terms like “lol” or “IMHO”. Being sarcastic with the spelling issues is just that, sarcastic. But, enjoy the pin hole view. Notice the view is fairly limited though.

Just like the opinions!

nate ogden
Guest
nate ogden

http://detroit.cbslocal.com/2011/05/04/report-nearly-half-of-detroiters-cant-read/ According to a new report, 47 percent of Detroiters are ”functionally illiterate.” The alarming new statistics were released by the Detroit Regional Workforce Fund on Wednesday. Do you need me to post graduation rates for you? On top of that spend a couple years running a business and hiring people then tell me how high your opinion is, and most of the people I interview have college degrees. “Yes, like the budget “crisis” we just witnessed,” Yes like the budget crisis that was not a crisis at all. The only crisis is Obama had to change his vacation plans.… Read more »

BobbyG
Guest

” liberaql dishonesty and stupidity.”
___

Un, no comment…

nate ogden
Guest
nate ogden

Bobbyg

“Primary colors an(SIC) numbers”

who doesn’t know and is spelled with a D?

BobbyG
Guest

Once or twice every so often are typos. Everyone makes them. But… your record here speaks for itself.

“fare enough”?

😉

nate ogden
Guest
nate ogden

it ignores the point of why bring them up in the first place? What does typing or spelling errors have to do with an argument? If the constitution was riddled with spelling errors does that make it any less of an important document? If The Odyssey was full of spelling errors does it make it less profound of a piece of work? So back to the question, why do you bother pointing out typing and spelling errors? Is that your only argument in support of what you believe? Your ideas are weak and flawed but you spell them better so… Read more »

BobbyG
Guest

“why do you bother pointing out typing and spelling errors?”
___

Nate, che care you take with your composition is a reflection of the care you take with your views. That’s all.

Just my opinion, of course.

DMD:

“Being sarcastic with the spelling issues is just that, sarcastic.”

Just your opinion, of course.

BobbyG
Guest

Oops, made another typo. It’s the Bordeaux and the fact that I’m watching the Tea Party debate on CNN in an EyeTV window while typing. Must be more careful.

Lay into me, Nate.

Margalit Gur-Arie
Guest

‘Most Americans are poorly educated and worst yet not even interested in the truth.” I am sorry that you have such a low opinion of American people. I happen to think that American people are a lot smarter than that and as they consistently shown over the years, sooner or later, they will make the right decisions. This is why I want people, ALL people, to come out and vote, and not just blindly vote for the guy with the best hairdo, but vote for their own interests. “Liberalism is built on lies. Liberals trick an ignorant public into thinking… Read more »

nate ogden
Guest
nate ogden

if your going to waste so much time trashing them why don’t you invest the 30 seconds to learn what your talking about

http://finance.yahoo.com/q/ks?s=WMT

Profitability
Profit Margin (ttm): 3.87%
Operating Margin (ttm): 6.00%

Compare that to Apple

Profitability
Profit Margin (ttm): 23.53%
Operating Margin (ttm): 30.43%

or Google

Profitability
Profit Margin (ttm): 27.05%
Operating Margin (ttm): 33.62%

John Ballard
Guest

And EBITDA?
Lotsa ways to skin a cat.

nate ogden
Guest
nate ogden

true EBITDA is a great way, your right a ton of honest ways to make the comparison then the argument, one that is never honest though is revenue

Wal Mart
EBITDA (ttm): 33.81B

Apple
EBITDA (ttm): 32.08B

Google
EBITDA (ttm): 12.78B

DeterminedMD
Guest
DeterminedMD

respectfully, Ms G-A, while I would not cite a specific percentage that implies the majority of Americans are poorly educated or not interested in the truth, for me if it is more than 20%, and per my interactions as a doctor and member of my community 1 of 5 reflecting this type of mentality and expectation seems fair, that is not very good as a reflection of our culture. Dependency can be very pathological. And if you have government representatives who either innocently or purposely push to increase dependency, does it really matter in the end how the agenda is… Read more »

Margalit Gur-Arie
Guest

Hi Dr. D., I cannot disagree with you about education being less than optimal and engagement being measly, as reflected in voting percentages every two years. Yes, we can do better, but I have to trust that the people can do better, otherwise what would be the point of Democracy? We need to be able to govern ourselves, or suffer the consequences. I agree with you on the pathology of dependency and I agree that we need to change the way we provide support to people who are in a vulnerable situation. Poverty is the #1 enemy of our society… Read more »

John Ballard
Guest

Dr. D, Ms G-A, This thread is drifting into deep water now. (Mind if I order another drink?) If I can add my two cents, your mention of a few points made me think of these… –DEPENDENCY. I agree with both of you that this is a problem. And efforts to help people too often have dependency as the unintended result. That expression “A hand UP, not a hand-OUT” is how it’s sometimes expressed. My guess is that everyone can cite examples of both from personal experience. I have observed both in my own family in the case of public… Read more »

nate ogden
Guest
nate ogden

John do you feel wealth disparity is a fare measure of anything? In broad terms is wealth not earned/acquired/made, in which case someone who does not work should not expect any increase in wealth, where as those who are working will see their wealth increase. As more and more people, many not Americans, become dependent on the welfare state they are no longer working. Why are we surprised at an increasing wealth gap in the same discussion of a declining work force? Minimum Wage for example does not take into account minimum standards of labor offered in return. To be… Read more »

BobbyG
Guest

‘wealth disparity is a fare measure”

Maybe on the BART. But, no, everyone pays the same for each destination.

nate ogden
Guest
nate ogden

“As to work ethics, there is a huge and increasing percentage of Americans who work for increasingly large employers.” Not to pick on you Maraglit but you keep spouting off lie after lie. Which is really ironic in a discussion of Amerian ignorance and lack of education. “Small Business is creating 60 to 80 percent of all new jobs in America” “Many visitors from abroad are surprised to learn that even today, the U.S. economy is by no means dominated by giant corporations. Fully 99 percent of all independent enterprises in the country employ fewer than 500 people. These small… Read more »

John Ballard
Guest

“The United States has fewer small businesses than any other developed nation”
http://shr.tn/0774

“And, conversely, the United States has the largest share of workers in big enterprises — defined as companies with 250 or more workers.”
http://t.co/Cp1tPum

Margalit Gur-Arie
Guest

And how are those about.com numbers trending (“increasing”) for you since, say, 1900?

nate ogden
Guest
nate ogden

? no idea what your trying to say

nate ogden
Guest
nate ogden

250…sounds like a nice arbitrary number chosen to make a point and not for its accepted standard or commonality. How do we have a Small Business Administration that goes up to 500, 1000 or higher depending on industry? Wouldn’t a large business in a nation of 1 million be smaller then a large business in a nation of 300 million? your other link is to twitter but doesn’t work. you link to some academics pushing governemnt healthcare which cherry pic stats. Read the report, there are more ifs and buts in the OCED data then I could count. The legal… Read more »

nate ogden
Guest
nate ogden

“And what would be the point of that exercise in futility, Nate?” To stop people like you from destroying this country. You might be a lost cause but for every person like you that aggresivly spreads these distortions there is 100 sitting back just reading not quit sure what to think. Most Americans are poorly educated and worst yet not even interested in the truth. They believe in what is handed to them. If all that these people see are your overstated lies the easy path is to believe them. If your confronted with reality and forced to back up… Read more »

John Ballard
Guest

Don’t hold back, Nate. Tell us how you really feel.