Health Wonk Review: Health Insurance in China over the Past 50 Years; A Review of The Autistic Brain; Stay Calm, Obamacare is On Track

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The newest edition of HealthWonk Review, a round-up of some of the very best recent healthcare posts, is now online.
Colorado Health Insurance Insider’s Louise Norris hosts this mid-summer edition of the review. She offers summaries of intriguing posts, along with evenhanded, insightful commentary. Both will help you decide which posts you want to read.
Many of her reviews whetted my interest. But here I want to call attention to just two entries covering topics that we don’t often read about on Healthcare blogs, as well a reassuring sane post summing up what Washington insiders say about the state of Obamacare. It will be a bumpy ride, but it’s heading into the station.

A History of China’s Health Care System

Norris reports that on :“The Healthcare Economist,  Jason Shafrin, brings us a great summary of health insurance in China over the past half century. Until the end of the 1970s, there were three main health insurance systems in China that covered nearly everyone.
“But the wheels started to come off after that; by 1998 almost half of the urban population had no health insurance, and by 2003, 95% of the rural population in China was uninsured. “
Shafrin explains that a shift to “fee for service” health care seems to have exacerbated the problem: “Some have claimed that the stark increases in health-care are due to provider profit-seeking behavior in China’s fee-for-service system. . .
“This price structure that was originally intended to cross-subsidize the delivery of basic interventions creates perverse incentives for providers to supply sophisticated care wherever possible, by shifting demand from low-margin basic services to high-margin high-tech diagnostic services and drugs.”
Does this sound familiar?
The good news is that China, like the U.S., has set out to reform its enormous health care system.For details, see Shafrin’s post. .
As Norris observes: “While plenty of progress has been made there is still a long way to go.”
She could have been talking about either country.
Norris also spotlights Jared Rhoads’ review of The Autistic Brain by Temple Grandin. “If you’re interested in autism,” Norris writes, “Jared’s summary [suggests] that this book is a good place to start learning more. I’m adding it to my list of books to read, so thanks for the tip Jared!”
Here’s just a snippet from Rhoads’ review: “Gradin and coauthor Richard Panek trace some of the clinical history of the condition, explain what can and cannot be gained from techniques like neuroimaging, and share what they believe are some good child-rearing strategies for parents with autistic children. . . .
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Under Obamacare, Will You Receive a Subsidy to Help You Buy Your Own Insurance? We Now Have Real Numbers That Will Let You Calculate How Much You Will Receive

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Note to Readers: A longer version of this post appeared yesterday on HealthInsurance.org.

Up until now, when Obamacare’s supporters and reform’s opponents squabbled over what insurance will cost in 2014, they had to rely on estimates and national averages. But now we have real numbers.

Eleven states have announced the rates that insurers will be charging in their Exchanges-marketplaces where individuals who don’t have employer-sponsored coverage can shop for their own insurance.

Subsidies Will Be Based On the Cost Of A Silver Plan Where You Live,

Middle-income as well as low-income people buying coverage in the Exchanges will be eligible for government subsidies that will come in the form of tax credits. Anyone earning between 100 and 400 percent of the federal poverty level (FPL) (now $11,490 to $45,960 for a single person, and up to $126, 360 for a family of six) will qualify.

Most people who are forced to buy their own insurance earn less than 400% of FPL. More affluent Americans usually work  for companies that offer comprehensive coverage.

The graph below shows average Silver plan rates in the eleven states that have disclosed premiums. (Note that these are only state averages. Premiums vary widely within a state: In some cities and counties silver plan rates will be much lower, even before you apply the subsidy.

Silver plan premiums

It’s worth noting that in these 11 states the least expensive Silver Plan costs 18% less than the non-partisan Congressional Budget Office projected last year. 
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The Business of Making Babies: How Much Hype and How Much Hope?

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Miriam Zoll’s  Cracked Open:  Liberty, Fertility and the Pursuit of High Tech Babies   is in part a moving memoir, in part a troubling expose of yet another  unregulated corner of our healthcare system. In this case it is  an industry that offers women everything from in-vitro fertilization (IVF)  to another women’s eggs-for-sale.

Zoll titles her first chapter “One Egg, Please and Make it Easy.”

If only it were that simple.

Zoll begins by acknowledging how naïve she was:

“I am an official member of the Late Boomer Generation. We grew up . . . . in the 1970s and ‘80s, watching with wide eyes while millions of American women—some with children and some not—infiltrated formerly closed-to-females professions like medicine, law, and politics. This exodus from the kitchen into the boardroom created a thrilling, radical shift in home and office politics, in the economy, and in relations between the sexes.

“‘Shoot for the stars,’” some of the more thoughtful women advised us, “’but don’t forget about the kids.’”

Zoll herself became one of the trailblazers. She is the founding co-producer of the original “Take Our Daughters to Work” Day, and on the board of “Our Bodies Ourselves.” In 2005, she became a Research Fellow at MIT’s Center for International Studies. There, her widely –published research addressed gender inequity and poverty in HIV/AIDS-affected households in sub-Saharan Africa.

At 35, Zoll married. At 40 she reports, she looked in the mirror, and decided:  “It’s time to have a baby.” Finally, she felt confident that she would be a good mother.  It didn’t occur to her that she might have trouble conceiving.

“We are the generation that . . .  came of age at a time of burgeoning reproductive technologies,” she explains. “We grew up with dazzling front-page stories heralding the marvels of test-tube babies, frozen sperm, surrogates and egg donors; stories that helped paint the illusion that we could forget about our biological clocks and have a happy family life after—not necessarily before or during—the workplace promotions.”

Zoll goes on to chronicle her own long trek through our multi-billion-dollar fertility industry. At the beginning, she and he husband were as innocent as most couples who believe what the media had told them: “Science and technology have finally outsmarted Mother Nature.”  Just because you’re over 40, this does not mean that you can’t conceive.

That final line is absolutely true.  Each year in-vitro fertilization and other forms of Assisted Reproductive Technology (ART) produce miracles.  The extraordinary joy that parents who thought that they could never have a child feel when holding their baby should never be discounted.  When the right patient receives the right therapy at the right time, these technologies can heal broken hearts.

                                             The Odds 

Neverthless, although 15 states mandate that insurers cover in vitro fertilization  the Affordable Care Act does not list IVF as an “essential benefit” that insurers must provide.

ART is still a medical experiment. Or, as Zoll puts it “ART is a crap shoot.”  In many cases, physicians don’t know why some couple succeed and others do not.  No one keeps tabs on who wins and who loses.  We have a National Joint Replacement Registry, a database of information that surgeons can consult as they learn why certain procedures work for certain patients while others go awry. But there is no official registry for in vitro fertilization—despite the fact it is an infant science shot through with uncertainties.

As Minnesota law professor Michele Goodwin and Judy Norsigian, Executive Director of Our Bodies Ourselves, warn in the Foreword to Cracked Open: “While the ‘better’ fertility centers now claim live birth rates of 50 percent or more, the national average remains at about one-third. It is easy to misinterpret pregnancy rates—which are high but often end in miscarriage—as live birth rates, which are much lower in comparison.”

Here are the facts: the most recent data from the Centers for Disease Control and Prevention reveal  I.V.F. failure rates as high as 68 to 78 percent in women ages 35 to 40, and 88 to 95 percent among women 40 to 44.
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Boehner Asks: “Why A Break for Businesses Only?”

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 That House Speaker John Boehner would ask this question shows either:

a)    how little he understands about the Affordable Care Act; OR

b)    how committed he is to making sure that the American public  does not understand the purpose of health care reform.

I would pick “b”.

Republicans are now suggesting that if the employer mandate (requiring that businesses offer benefits to their workers or pay a penalty) is being postponed until 2015, the Obama administration should postpone the individual mandate as well.

“Is it fair for the president of the United States to give American businesses an exemption from his health care law’s mandates without giving the same exemption to the rest of America?” Boehner asks.

What he ignores, of course is that under the Affordable Care Act, .middle-income as well as low-income citizens would receive generous tax credits to help them purchase insurance. Not long ago, I wrote about those subsidies, and a new “subsidy calculator” that will let an individual estimate how large his subsidy would be).

More than 26 million Americans will be eligible for these tax credits next year–though most dont know it. And by attempting to delay the individual mandate, the GOP is trying to make sure that they don’t find out.

       The Individual Mandate and the Employer Mandate Are Not Connected

Meanwhile Boehner pretends that the two mandates are somehow connected, In fact, they have nothing to do with each other. 

 The individual mandate exists because, under Obamacare, insurers are required to cover people suffering from pre-existing conditions. Aetna will no longer be able to shun the sick, nor will it be able to slap them with sky-high premiums.

This part of the law is extremely popular. Most Americans understand that any one of us could be diagnosed with cancer tomorrow. The goal of the law is to protect all of us against the vicissitudes of fate by ensuring that we have access to affordable insurance.

But if there were no individual mandate requiring that we all purchase insurance (or pay a penalty), a great many people would wait until they became ill, and only then buy insurance.As a result the insurance pool would be filled with folks who need expensive care, and everyone’s premiums would spiral.

If we want to insist that insurers cover the sick, we also must insist that everyone join the insurance pool. We all share in the risk of becoming sick, and so all must share in the cost. Ultimately, insurance is all about “pooling the risk.”

(Those who believe that they shouldn’t have to join the pool because they are young or  because they don’t smoke, exercise regularly and generally “take care of themselves” are ignoring the most basic fact about the human condition:  “all flesh is grass”. )

The requirement that insurers must cover a 30-year-old suffering from MS cannot be separated from the individual mandate. We cannot have one without the other. The architects of health care reform understood the connection

By contrast, the employer mandate has little to do with the individual mandate. The phrases sound alike, that’s about it. The individual mandate and the employer mandate do not depend on each other.

If some employers decide that they will wait until 2015 before offering comprehensive, affordable health benefits, their employees will be eligible for subsidies to help them purchase their own coverage.  Postponing the employer mandate in no way affects their ability to obtain coverage at a cost they can afford. Alternatively, if an individual decides not to purchase insurance, next year, he will be asked to pay a penalty of just $95.

This is what Fox News calls “a hefty fine.”

 

The Employer Mandate is Postponed: What Does This Mean For Obamacare? Is Ezra Klein Right–Should the Employer Mandate Be Repealed?

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The administration has announced that employers with more than 50 employees will not be required to offer insurance to their employees until 2015.

Originally, reform legislation said that these employers would have to offer affordable, comprehensive insurance next year—or face penalties of $2,000 to $3,000 per worker

                              Proof that Obamacare is Not Working?

Without missing a beat, Republicans have stepped forward to say that the delay is evidence that Obamacare is faililng.

What they apparently doesn’t know (or doesn’t want you to realize) is that a delay in  the employer mandate will affect only a fraction of employers, and very few employees

First, the majority of large companies already offer health insurance that includes the benefits that the Affordable Care Act labels “essential.” (The only exceptions tend to be large restaurant and retail chains)

The mandate will have the biggest impact on small companies that today, may offer insurance, but often don’t provide “comprehensive” coverage. The postponement means that these firms will have another year to think about whether they want to expand coverage—or pay a penalty,

But their employees will not be hurt by the delay.  If either a restaurant chain or a small firm doesn’t offer benefits next year, both full-time and part-time workers be able to buy their own coverage in the Individual Exchanges where the majority will be eligible for generous tax credits. The coverage available the Exchanges will be just as good as the insurance their employers will be required to offer in 2015.

As former White House health policy adviser Zeke Emanuel pointed out today on MSNBC’s “Morning Joe”:  “The delay of implementation of the employer mandate will impact a limited number of companies. I actually don’t think this is that big a deal,” .

Emanuel went on to point out that the “the provision only applies to employers who have 50 or more employees. He estimated that there are ibkt  200,000 total employers in the U.S. [who would be] impacted and that “94 percent already offer health insurance” to employees.

Emanuel’s estimate may be high: “You’ve got 5.7 million firms in the U.S.,” says Wharton’s Mark Duggan, who served as the top health economist at White House’s Council of Economic Advisers from 2009 to 2010. “Only 210,000 have more than 50 employees. So 96 percent of firms aren’t affected.

“Then if you look among those firms with 50 or more employees, something on the order of 95 percent offer health insurance. So it’s basically 10,000 or so employers who have more than 50 employees and don’t offer coverage. Those companies probably employ around one percent of American workers.”

 To Judge the Success of Obamacare , Don’t Over-React to Day by  Day Headlines

Emanuel  also urged taking a long-term view of what the Affordable Care Act is going to accomplish, saying: “We need to look for 2020 rather than moment to moment for changes in the system.”

I couldn’t agree more. Reforming U.S. healthcare is an enormous undertaking. As I have said in the past, it will be a process, not an event. Along the way, there will be glitches. Each time, reform’s opponents will jump up and down, insisting that the End is Nigh. Obamacare is dead.  We must  ignore them—take the long view, and forge ahead.

I am hopeful that by 2020  reform’s goals will be realized. Even then, we will continue to modify and improve reform legislation over a period of years, just as we have revised Medicare.

The notion that we must “rush” to implement every aspect the ACA is misguided. When attempting to enforce the employer mandate, an emphasis on “speed” could lead to the “train wreck” that Republicans predict. 

What is crucial is that the “Patient Proteciton and Affordable Care Act” protects as many  Americans as possible, as soon as possible, while making medical care affordable by giving those who must buy their own insurance the subsidies they need. In 2014, this will be happening.

In the meantime, we already have begun to rein in health care costs, slowing healthcare inflation from 7% or 8% a year to roughly 3%. This is only a start, but a very good start.                               

                         How Will the Delay Effect the Mid-Term Election?

Predictably, some conservatives are crowing that the delay represents a “huge set back” for Obamacare. “The Obama administration has undermined its sole claim to greatness and delivered a blow to Democrats on the ballot in 2014,” writes Washington Post conservative columnist Jennifer Rubin. /

 In truth, this is far from a major setback for reform. Apparently Rubin doesn’t realize how few employers will be affected, and perhaps she doesn’t understand that without the employer mandate, even if these employers don’t offer benfits, the majority of their workers will be eligible for tax credits in the Indivudal Exchanges,

As for the effect on candidates running in 2014, even Fox News recogizes that Republicans, not Democrats are most likely to be hurt. 

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Health Wonk Review Is Up: A Superb Summary of Provocative Healthcare Posts

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The latest edition of Health Wonk Review is now up on Wing of Zock.

 Sarah Sonies and Jenifer Salopek have done a superb job of summarizing some of the most provocative healthcare blog posts of the past two weeks. 

Here are just a few of the questions these posts  raise:

—   Should states mandate nurse staffing ratios in acute care hospitals?

— What can we learn about early Medicaid expansion in some states?

—   Why do we need more research into the value of colonoscopies?

I won’t try to summarize the posts. Just go to Wing of Zock                    

If You Buy Your Own Insurance in the Exchanges, Will You Receive a Government Subsidy? How Much Will it Be for Couple, or a Family of Five?

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ACA tax credits

 

 

 

 

 

 

Source:

No doubt you have read that if you are single, and earn less than 400% of the Federal Poverty threshhold (roughly $46,000 for an individual or $94,200 for a family of four) you will be eligible for a tax credit to help you cover the cost of insurance premiums.

But most of us don’t fit into one of those two categories. What if you are a couple, or a family of three? What happens if you have four kids?.

As the table above reveals, if a couple has  four children  and earns less  than $126,360 (400% of the FPL), they will be elibigle for the tax credits. Note: these credits are available only if you are self-employed, unemployed, or work for a company that does not offer affordable, comprehensive insurance. “Affordable” is defined as individual coverage that costs less than  9.5% of your income.

The credits are designed to make sure that no one who purchases their own insurance is forced to spend more than 9.5% of their income on health care. For instance, according to the Kaiser Family Foundation’s (KFF’s) new subsidy calculator, coverage for a 35-year-old couple with three children might cost $13,101./(This is an estimate; actual premiums will vary depending on where you live. Healthcare is much more expensive in some states than in others. ) If the parents earned roughly $100,000 a year, they would be asked to pay $9,500 toward their insurance and would receive a tax credit of $3,626.

This assumes that they purchase a “silver plan” which pays for an average of 70% of covered benefits. The family would owe the other 30% in  the form co-pays and deductibles. But keep in mind that preventive care is free, there are no co-pays and the deductible does not apply.

Assuming they need care other than preventive care, total out-of-pocket spending would be capped at $12,750, even if the entire family wound up in a car accident, three of them were hospitalized, and two needed surgery.

If they preferred, the family could purchase a less expensive Bronze plan which would pay for 60% of covered benefits. Their co-pays and deductible would be higher, but once again, preventive care would be free, total cost sharing still would be capped at $12,700, and the premium for a Bronze plan would be lower: KFF estimates that a family of five earning $100,00 would still receive a subsidy of $3,626 and their share of the premium would be just $7,253.

Why is the Government Subsidizing Households That Earn more than $125,000?

 If people choose to have four children, that certainly is their business. But why should I help pay for their healthcare?

The answer is two-fold:

First, people don’t necessarily choose to have 4 children –or more. Some couples are surprised (not to mention overwhelmed) when they disccover that they are having twins or triplets. 

Secondly as a society, we care about children. We don’t want any child to go without needed care.

But there also is a pragmatic reason for supporting large families. If those children don’t receive preventive care such as dental checks as well as  timely treatments when they are sick, down the road, we as a society will pay the price. The health of the population will play a major role in determining how productive we, as a nation, are.  

 

 

 

 

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Obamacare: In 2014 Will Workers Be Able to Afford the Health Benefits Their Employers Offer?

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Recently AP floated a story that spread like a virus. Within a day it was picked up by Yahoo!,  the Wall Street Cheat Sheet, and the Washington Post  where it was headlined “Affordability Glitch.”

Thanks to a “wrinkle” in the law, the story warns, Obamacare may hurt many of the people it is supposed to help, by making “health insurance unaffordable for . . . workers employed by restaurants, retail stores, hotels, and small businesses.”  The law is explicit, AP explains: “companies that employ 50 or more workers must offer ‘affordable’ coverage to those working more than 30 hours per week — or face fines. ‘Affordable’ health insurance, as defined by the legislation, means that premiums can cost no more than 9.5 percent of an employee’s income. . . .    . . . For low-wage workers, many of whom live paycheck to paycheck and earn barely enough to cover basic necessities 9.5% represents a lot of money.”  

True, but the fact that the law says premiums can equal 9.5% of income doesn’t means that employer-sponsored insurance will cost 9.5% of a worker’s pay.

Nevertheless, Yahoo! conjures up a hypothetical employee who will be left out in the cold: “Take, for example, a restaurant worker who makes $21,000 per year. A premium that costs 9.5 percent of this income would run $1,995 for the whole year, or $166.25 per month.  How could this employee possibly shell out nearly $2,000 a year for insurance?”  

He will have to turn down his employer’s offer, and then the government will demand that he pay a penalty because he didn’t buy insurance!
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Will Obamacare Kill Jobs? More Fictions and Facts

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— Fiction: No doubt, you’ve heard that Obamacare will cripple small businesses, the “engine of job growth in America.” In 2014 employers with more than more than 50 full-time workers will have to provide insurance—or pay penalties. If more than 30 of their workers go to the individual Exchanges and receive government subsidies in the form of tax-credits, the business will have to help cover those subsidies by paying a fine of $2000 to $3000 per employee.

Obamacare’s critics speculate that many employers will stop hiring, so that they have no more than 49 full-time employees.

–Fact: As of 2010, there were roughly 5.7 million small employers in the U.S. (defined as those with fewer than 500 workers.) Ninety-seven percent of them have fewer than 50 employees. In other wrods, Obamacare’s employer mandate applies to only 3% of small businesses.

And 99% of those  with more than 50 employees already offer insurance. The employer mandate will affect just a tiny sliver of small companies.  Lawmakers understood this when they wrote the legislation.

–Fiction: In 2014, many small employers will trim full-time workers’ hours and we will become a nation of part-time employees.  Small business owners know that if they have fewer than 50 full time workers (averaging 30 hours a week) they won’t have to pay a penalty, and their workers can go to the Exchanges where individuals can purchase their own insurance, and receive those generous tax credits.

–Fact: This bit of fear-mongering overlooks the fact then when the government counts “full-time employees” it doesn’t just count heads, it counts hours.The law says that the firm must offer insurance if it has 50 full-time “or full-time equivalent employees.”

Here is how the rule works: If a business has 50 full-time employees working 30 hours a week and cuts 10 back to 15 hours, it will have only 40 full-time employees. But it will have to hire more part-timers to cover holes in the weekly schedule.

Assume the company hires 20 new part-time employees, each working 15 hours a week. Because they will be putting in 300 hours a week the government will count them as ten “full-time equivalents.” Add those ten to the remaining 40 full-time workers, and the company then will have 50 full or “full-time equivalent’ -employees.

The business won’t have to insure the 20 part-timerswho work only 15 hours, but it will have to insure the 40 who work full-time—or pay the penalty..

This fiction also overlooks why employers offer benefits.   Research reveals that when a business insures workers, it enjoys higher productivity, better morale and lower absenteeism.

This explains why roughly 95% of companies with more than 30 employees provide health insurance.

 —Fiction: Chain restaurants, retailers and hotels can easily cut thousands of workers to part-time so that they don’t have to insure them.

— Fact:  Organizing a  company’s  hiring and staffing around making sure that it won’t have to offer health benefits is hardly a brilliant business plan

Imagine what cutting full-time workers’ hours will do to morale and productivity– not to mention customer service. 

 Consider this  Wal-Mart has stopped hiring full-time employees, and is relying on part-timers and temps. As a result, Forbes reports that Wal-Mart is experiencing  “complaints about understaffed stores with empty shelves and inventory piling up in warehouses and back rooms.”. 

“It seems even Wal-Mart can’t operate on such a lean staff,” writes Forbes contributor Laura Heller, who describes herself as “a retail geek/expert.”

“Dirty stores, parking lots in disarray and out-of stock products don’t bode well for sales and stores can’t operate that way for long periods.”

Meanwhile, Target, one of WalMart’s chief competitors, continues to offer health care benefits to part-time employees, even though the ACA doesn’t require that it insure them.
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Obamacare– Fear-Mongers Poison Minds; Hatred Blinds

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Judith Mayer Lynn, uninsured and battling breast cancer, should be a fan of the Affordable Care Act. Instead, Bloomberg  reports, she know little about it. When Bloomberg interviewed the 56-year-old she was unaware of subsidies in the law that will help people like her buy coverage in 2014,. “Lynn didn’t know the Affordable Care Act requiresthat insurers to pay for prescription drugs, hospital stays and other services she’s spent the last two years scrimping to afford. Nor did she realize she can no longer be denied a policy due to her illness”.

When told of the benefits, “Lynn remained unconvinced, skeptical of insurers and government alike. ‘It’s a joke,’ she said. ‘There’s going to be loopholes in all of these provisions.’”

If you showed Lynn the list of “essential benefits” that insurers will have to include in the policies they sell to people like her, could you persuade her to read the list—and explain where she saw the holes? Probably not. Her mind is closed.

In an interview at an Access to Healthcare office in Las Vegas, Lynn said she was unaware of those benefits — and didn’t trust Obama to produce them anyway.

                                            The Poison: Hatred

Perhaps I shouldn’t be surprised. We live in a nation where in 2009,  a U.S. Congressman felt free to shout out “You Lie” during a  televised presidential speech to a joint session of Congress.   

(President Obama had just said that the legislation would not mandate coverage for undocumented immigrants. This is, of course, correct.  South Carolina Rep. Joe Wilson (R) later apologized.)

Yet that didn’t stop another Congressional Republican from calling out the President earlier this month. In a scathing speech on the floor of the House, Rep. Jim Bridenstine (R-OK) derided President Obama as a “dishonest, incompetent, vengeful liar” who lacks a “moral compass.” Bridenstine cited HHS Secretary Kathleen Sebelius’ efforts to promote enrollment in the Affordable Care Act as one reason that President Obama is “not fit to lead.”

Bridenstine didn’t apologize. Instead, the next day he told a talk show host that he had “gotten great encouragement” for his remarks from fellow Republicans. /

I have followed U.S. politics for many years. Never have I seen a president so hated—not Nixon, not LBJ at the height of the War in Vietnam..

       Politicians Are Not Alone in Teaching Americans Not to Trust Obamacare

Lynn recalls one of her surgeons telling her that he was leaving the business because the health-care law dictates what he can charge patients. This, Bloomberg notes, is “something the legislation doesn’t do. “

Why would a surgeon claim that the Affordable Care Act will be setting his rates? Presumably he reads newspapers.  How could he be so uninformed?

“There is a lot of distrust,” Sherri Rice, chief executive officer at Access to Healthcare explains. When her nonprofit group began asking members about the ACA last month, about half knew little about its provisions and another quarter were “furious” about it, she told Bloomberg.

Such anger makes it difficult to think clearly—or take in information.  This may explain why Lynn’s surgeon thinks that under the ACA he will be told what he can charge patients. Perhaps he, too, is so “furious” that the facts don’t register. Hatred blinds.

 
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