text:
Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.
Friday, July 06, 2007
More Solutions, Long Post
Free health care isn't free. The money has to come from somewhere; the question is how to get it into a bucket, and then how most effectively to get it back out, to where it's needed. People frame it in all sorts of ways, depending on their political persuasions. Andrew Sullivan says that in arguing for government to pay, liberals would have us all be permanent supplicants. Brilliant. And it fits nicely onto a bumper sticker. But it's fatuous. If the ultimate virtue is the taking of money out of one's own pocket and paying directly for one's health premiums, then probably less than 10% of Americans are virtuous. (No comment.) Premiums are paid by employers, by governments, but by only a few individuals themselves (I'm among them.) We're already supplicants. (Well, not me.) If there were universal coverage, taxes would go up somewhere, but premium expenses would go down. The money that goes into the bucket, in other words, would be mostly a wash. Left hand or right hand, it comes and goes. My argument is, in part, that by eliminating the countless insurers and their enormous overhead (their profits, their executive pay and shareholder dividends -- not to mention countless redundant clerical no-sayers) you could fill the bucket to the same level and have lots left over. That would be good, by whatever method the money is taken from us, and by whichever agency it's given back in the form of health care. Package it with a name that makes you happy. Money comes from us one way or another, gets centralized somewhere, and returned in the form of plaster and penicillin. In what way does having insurers in the middle help that happen?
The always-thoughtful Eric worries: "The problem I have with single-payer systems is that I fear a serious erosion in innovation - what compels a single-payer to add coverage for a new-but-expensive lifesaving modality? If your choices are "take what you're given" or "pack sand and pay for it yourself", new technology won't be deployed to save people's lives nearly as quickly." He makes an important point, but, like my concern about monolithic control of reimbursement, it can be addressed (so says me, the non-politician, non-economist, non-systems-wonk) by having at the top panels of consumers and providers making reality-based (remember that bygone concept?) decisions. If such a structure were in place, given that we're now talking about a single entity instead of hundreds, it would be possible for providers and consumers actually to have control. This makes a strong argument for single-payor, as opposed to our current situation, wherein we're divided and conquered. How should such panels be constituted, by whom, with what feedback loop attached to the citizenry? I'm thinking, I'm thinking! But I'm guessing people much smarter than I could figure it out.
I haven't seen "Sicko" yet, but I've seen M. Moore's other movies, so I'm guessing that at its center, he has the problem right, and that in examples and solutions he's overplayed his hand with anecdotes and shot himself in the foot with hyperbole. Speaking of which, in a review of the film James Christopher of the London Times says, "What he hasn't done is lie in a corridor all night at the Royal Free watching his severed toe disintegrate in a plastic cup of melted ice. I have." Interesting: in my opinion, universal health care has no business covering the re-implantation of toes. Fingers, yes (depending on which ones). Toes, unh-uh. If surgeons use big toes to replace thumbs, -- and they do, they do -- that they are otherwise dispensible, foot-wise, is spoken to. A thing to which it is spoken.
And that gets us to the nitty-gritty. The bucket isn't bottomless. We can decide how much it holds, but at some point we also have to decide for what kinds of care the contents will be doled out; unless we want to make it bottomless, which we could in theory, but won't and can't in fact. Keep the costs down, we all say, except (you know what's coming) when the care in question is for us or our loved ones. "Spend a little as possible on them, and as much as needed on me" is a plan, all right, but is hardly a workable one. (Less so in the minds of one political party than the other). But let me be clear (since I've given myself the soapbox): I'm OK with tiers in the system. Not tiers of joy, to be sure. But this is America; plus I've said in my previous post that I think payments to providers ought to reflect quality of work: if I'm asking for rewards for the quality of my work, I can't begrudge it elsewhere. It's not without moral unclarity (if health care is a right, it doesn't automatically follow that people should be barred from obtaining different levels thereof), but the idea that there might be a difference between basic coverage given to all, and that available to those willing and able to spend more is one I can accept. It's just the way it is: a system that is the same for everyone with no avenue for opting up won't fly, pragmatically, at this point in the US; but one that provided everything for everyone under all circumstances will bankrupt us, absolutely, eventually. Heck, we're heading there (bankruptcy) already, on more than one track.
It's either/or. Either we decide as a nation that we're happy spending whatever it takes on health care, or we address the issue of rationing (ok, let's call it "prioritizing.") Some countries do it openly: in England, on "the National" it was true at least at one time that, for example, a person of a certain age with a certain percentage of body burn got supportive care only: pain medication, comfort. Some do it de-facto and maybe even cynically: in Canada you have to wait a long time for certain procedures, which means some don't get them, even though it's not specifically proscribed. A few years back a British orthopedic surgeon responded to outcry over long waits for hip replacement by saying that the line wasn't as long as it looked, since some people die while waiting for the operation. Probably the hardest thing any health care worker does is deciding when further care is inappropriate. It goes on all the time; it's just not formalized. Somehow, sometime, on paper and in public, it needs to be. A comatose hundred-year-old in kidney failure doesn't get dialyzed. A ninety-five year old? Not him, either. Sixty? Sixty-five? OK, eighty-five? And if the idea is repulsive -- which it is -- and if it simply can't be addressed (certainly Congress never will), then let's just agree that the best we'll ever do is nibble at the edges. Which, to date, has pretty much meant nothing more than continually lowering reimbursement to doctors and hospitals. Turnip. Blood.
Outraged comments on posts such as this notwithstanding, people willing to work extremely hard under lots of stress to provide an excellent product have a natural inclination to expect some sort of commensurate reward. Certainly no doctor expects to get as much as a mid-level executive for Healthcom, or as much as a second-string second baseman. But something that reflects work and which doesn't continually drop would be nice. The price for the current approach has been, and will continue to be, burnout of the best, and the looking elsewhere than medicine by the sorts of people you'd like to see choosing it as a profession. The problem with us goddamn doctors is that we're also human beings. Tell me what you think a colon resection is worth, then stop lowering the amount every year. And if you won't let me charge more on my own because I do a better job (every other professional does), then show me a way you'll try to figure out if I'm better and slip me a little something. If not, don't expect everyone to keep striving. It doesn't work that way anywhere else; increasingly, it's not working that way in medicine, either. Which makes the next paragraph, probably, wishful thinking.
There's one thing to do before playing the rationing card. Doctors, as a group, have a hard time with it; but it's coming, and it needs to arrive. To the extent that it has arroven (yes, I know), so far it's pathetic. I refer to finding out what works, why some doctors get better results than others, why some can get the same results as others at half the cost. Determining, in other words, "best practices." Finding that out and putting in place methods to encourage the good and eliminate the bad. Care, that is. What we have so far, referred to by the much unloved acronym "P4P" -- which stands for "pay for performance" -- is, at best, silly; and at worst, counterproductive, because it's so stupid. An example of bureaucracy at its worst, the list of parameters seems to have been generated by a committee with little input from actual practitioners. Big surprise. I know medical quality is hard to quantify, to solidify into a checklist. But for surgeons, for example, the archetype is getting pre-op antibiotics into the patient no longer than an hour before surgery. Funny. In training, we were told to get it infused at least an hour ahead of time, so tissue levels could rise and equilibrate. Yeah, you can measure it and write it down. But what goes on much before that -- in terms of selecting and planning an operation -- and after that -- in terms of carrying it out and in providing post op care -- has volcanically more impact that the ticks of the antibiotic clock. Everyone knows that. Getting a handle on it is where the action is; but if it's possible at all, it'll take a hell of a lot of work. Thousands of records will need to be reviewed, outcomes compared, methods dissected. Necessarily, judgment will be called into question, egos will be threatened. Worse, errors in data collection and analysis will be made; conclusions may be wrong sometimes, or tainted. The various specialty societies and colleges will need to be at the helm, and it'll take time and will generate lots of heat (with good planning, maybe enough to reduce oil imports), but in my opinion it has to be done. All doctors and nurses know it: there are good ones, and better ones. And some bad ones. Crazy maybe, but I think most docs -- given the right incentives and handled in constructive ways -- will respond to information that allows them to do a better job, even if it means admitting that they may not have been in the past. Scream, yell, get pissed off, feel insulted. Then lie awake at night and think it over, look yourself in the mirror when you get up. And make some changes. Been there. Done that.
To the extent that people running for president are addressing health care at all, keeping the money-changers between consumers and providers seems to be a given, which strikes me as feckless and crazy. Why should a national health-plan include a layer which provides no care, is clearly dispensable, and which serves to suck huge amounts of money out of the system? It's like paying someone to put the key in your car before you start it.
So my thoughts distill to three things, needed in this order: a single-payor system that includes real and actual control at the top by providers and consumers; a no-holds-barred effort to find and encourage (enforce) best practices, which recognizes and rewards excellence; and, when all the money that's possible to save has been saved, the toughest of them all: prioritizing care; deciding which expenses make sense, and which don't -- rationing. (Alternative to number three: stop complaining about costs of health care.)
(I suppose it's not trivial that if the insurers were really to go away, there'd be lots of decent people without jobs. But that's hardly a reason to keep a useless system going. Maybe some of those displaced would be willing to do those jobs that, you know, Americans don't want to do. That way we could solve immigration, too.)
28 comments:
You state that the solution is an either/or. In my experience, that is only true when we confront this as a problem-to-be-solved. The decision becomes "Which hole in the dam shall we plug?" rather than "How do we keep the town dry?"
My experience in the world of healthcare is in asking that bigger question - the one that starts at the place of agreement: "What would it look like if our community / country were healthy? And how do we establish the conditions for that to happen?"
If we continue to see our nation's health as a problem-to-be-solved, we will never be healthy. The very best we could hope for under that scenario is to be "not sick." - 7/06/2007 8:48 AM
- Sid Schwab said...
Hildy: it's a good point. But I think it's on a separate track: achieving maximum good health is, I agree, a major goal. Still, until perfection, paying for health care will still be needed. So it seems that whereas the costs and savings are intertwined, I think we still need people addressing each problem, separately. (Interestingly, I just read an article showing that all the efforts to get kids to eat healthy are failing.)
- Pursey Tuttweiler said...
Good Lord, lots of food for thought. I will have to take more time to read this thoroughly and check back, but I do like what you are saying about the politicians views of this. The thing that is so incredibly frightening is that the economic disaster that would follow a single payor system is enough to keep the money makers from ever letting this happen and a politician who truly pushes for this will find their career cut unexpectedly short. Ann Richards took on the insurance giants, and i cannot fathom how she could have lost to G.W. for Governor when she ran for her second term, but she did. Hildy, the huge corporate giants would not survive if folks were healthy. What would happen to pharmaceutical companies if cancer were cured or diabetes disappeared? What is the incentive for health and who gains, except of course the healthy person? And these initiatives for healthy diets, how can they succeed when the fast food giants have private contracts in schools. Oh, and I live near a very wealthy high school and there is a Pizza Hut, a McDonalds, a Taco Bell, a Sonic, etc. within a stones throw. The lovely high school young women, even the athletes and cheerleaders have the cutest figures and huge guts. They have middle aged spread in their teens. What is up with that? It cannot be healthy to be a size 4 with a beer gut at age 18. It has to be the diet. Oh well, as you can see, I have a lot to say. Sid, I stopped by to let you know that I tagged you to post 8 random things about yourself. If you don't want to, that is fine, but it can be fun. - 7/06/2007 9:59 AM
Thank you Dr. Schwab.
- Eric, AKA The Pragmatic Caregiver said...
"always-thoughtful" - cripes, I'm in deep dung now.
Not that I'm employing a divide-and-conquer strategy here, but I want to go back to the part about single-payor being necessary.
I agree that for-profit insurers are eeeeeeevillll. I know - my mom (she of the looming lifetime cap) and I are insured by (the same) one. I don't think they have efficient business process, I don't think they have a Calvinist approach to internal costs, and I agree that they make their money by denying payment as frequently as legally possible and as long as permitted, plus two weeks. They are tools, and I actively dislike them as an organization and everyone I deal with there as subhuman beings.
Fortunately, they've shot themselves in the collective feet so many times that they are a topic of humorous conversation, or, when they somehow screw up the orthopedist's charges, humerus conversation.
The thing is, we're stuck with them - because our group is headed for actuarial death spiral (older, sicker, underserved area), we can't effectively change carriers. They can't dump us, but by god they can uprate us the most the state will allow every year, and see if we'll drop of our own accord. We're too stubborn to do so; mom's continued living is, in part, a giant eff ewe to our insurer, which makes it all the more delicious.
I think the local nonprofit Blue would be a stellar choice for our health care brokerage. In fact, the very same nonprofit Blue paid Sid's fee in 1983, without much managed care involvement - it was one of their traditional indemnity plans. Now they won't take our group for love nor money. That's not right; one sick person out of 120 shouldn't make a firm uninsurable. The prudent thing would be to fire my mom, COBRAing her coverage to the current carrier, and then changing the 119 other less-dead members to the Blue, whose computers will suddenly recognize us as less of a ticking time bomb. Until someone else gets sick and the cycle starts anew. In a company our size, *one* employee with something like metastatic breast cancer, relapsing-remitting MS treated with one of the biotech drugs, or a kid born with a bad heart, and we teeter on being branded untouchable.
Listen to what I'm saying: we should fire a woman with advanced cancer. My *mom*. The idea is reprehensible, but the reality is, without familial ties, people do get shitcanned by small businesses to control healthcare costs. It's never so tackily overt - usually, if they're that sick, their work performance suffers, they run out of sick leave, etc, etc, etc. It happens, though - and so long as the rules allow carriers to cherry-pick groups that are statistically unlikely to actually use all the healthcare they paid for, it's gonna keep happening.
Community rating is more important than single-payor. When everybody's in the pool, sick moms get paid for by well young men. That's how the Blues worked for decades. Everybody of a certain age and gender paid the same price, and I believe the doctors were pretty happy about it, because reimbursement levels started slipping when upstart companies figured out how to use statistical modeling to keep the premiums low to attract the healthy ones who would never use it while keeping those who might use what they paid for either out of the pool (refusal to write) or kick 'em out when they got there - (adjusting next year's premium based on claims experience).
To keep well young men in the pool, there's got to be some incentives and some disincentives for failure to pay and play. Otherwise, anomalous deathspirals occur - PacifiCare and QualMed are good examples in the Pacific Northwest of carriers whose models broke under the strain when those subscribers fled and only the truly-desperate remained.
Yes, single-payor is one way to handle this. It's not the only way, though. Medicare isn't *really* single-payor; yes, CMMS nee HCFA determines with broad brush what gets paid for, and it's better than it used to be (with the separate Part A intermediaries and Part B insurers), but when the rubber meets the road, it's still a federation of independent (profit-making) entities issuing local coverage decisions, and that makes me nervous. Aunt Sadie in Boca and Aunt Lizella in Scottsdale shouldn't be treated differently for the same diagnosis because of which government contractor is paying the bills, but they can be as it stands now. Independent for-profit entities making coverage decisions seems to be a tradition we've created with Medicare.
Sid: here's a direct question for you....
"If the marketplace was truly level for all carriers through enforced community rating, mandatory coverage and true portability (ie, you could switch at will, and your employer/the government (choose one) gave you a pile of money to go buy coverage in the individual market), why couldn't companies compete on customer service, coverages, provider networks or any other set of benchmarks?"
What's so wrong with some healthy competition if it drives down costs? By moving the incentives away from "make the most money through statistical arbitrage" to "compete for customers through quality", you change the game.
Eric, Who Is Really Fired Up About This At The Moment - 7/06/2007 10:57 AM
Why do think that a single payer system-as it would be sewed together in this country by the usual suspect special interests groups-would not be "administered" by the same group of insurers much to their profit?
- Sid Schwab said...
Eric: I guess they could, and maybe they would. I doubt they'd subject themselves to those sort of controls -- they pretty much make the legislation, don't they? If it were to come to pass, the customer would benefit in terms of service, in theory. But still: the service they provide, at best, is answering phones and emails, and maybe helping with forms. It's not really of unique value. It's brokering (emphasis on "broke.") I admit my perspective is heavily influenced by watching the numbers of people employed by my clinic, just to deal with insurance companies, steadily increase to the point of taking over an entire former bank building (perfect). Two floors of cubicles, and I'm sure it's way more now. That's a lotta dough, especially when multiplied by thousands of hospitals, clinics, offices. And that's just on the provider side... And think how much easier it would be for you and your mother if there were one system, one set of rules, no need to plead for coverage. Input some data, get covered. Put a tooth under your pillow....
- Richard said...
Sid, your post is strangely similar to where the Canadian health system is going.
Public discontent over the infamous "wait-lists" ignored by Michael Moore in Sicko has led towards a move to allow private companies to provide health care.
The real stickler is whether such care is paid for by the government (keeping to the single-payor model) or by the patient. Privately provided but publicly funded care is what just about every family doctor is. When it comes to elective surgeries and care beyond the primary care physician, private provision seems to provide some competition to encourage the public system to innovate and improve, but also ends up putting public tax dollars into a few private pockets. However, given the conservative nature of most western governments, "public-private partnerships" are here to stay for the near future and will increasingly be a mainstay of Canadian health for elective and outpatient care.
The main argument against privately funded and provided care in Canada is that such a "second tier" would draw on the resources of the public system (doctors, nurses, and other health care professionals trained at such a high public cost). The workaround has been demonstrated at the False Creek Clinic in Vancouver, where patients can consult an ER physician for a (hefty) fee. The physicians employed under at this urgent care clinic do not participate in the public system (and I also believe that some of them are foreign-trained). Nevertheless, technically this clinic is a violation of Canadian laws on health provisions, and it will be interesting to see how the Canadian government reacts and whether this business model will succeed. - 7/06/2007 12:31 PM
- rlbates said...
Good post Dr Schwab. Good comments. But I know from trying to have reasonable discussions with family and friends that when it comes to rationing care, it can get heated real fast. For example, why should most of the infertility procedures be paid for by health insurances? When has having a baby ever been important for physical health (yes, I could argue for emotional health)? Notice how many more premies there are with the multiple births from insemination procedures? We cover these, but how much mental health coverage do these same insurances provide? It gets tough real quick, but I agree it is needed. The pie is only so large. Too bad we can't do the same as Jesus did with the fishes and loaves.
Sorry, Sid, I'm not buying. The only way to get single payer is for the govt to be the payer. I want to see the govt run any other system efficiently and humanely before they get their hands on the profession that I have dedicated my life to and everyone depends on to stay alive and well. The only reason the post office works as well as it does is that it has some competition in FedEx, UPS, DHL, and it takes more and more $ to do less every year. Let the govt run a basic clinic system if it wants to try, but it's mandatory to have some private competition.
The only way to get young healthy guys to join the insurance pool is for there to be serious consequence for not joining. These guys are unlikely to get colon cancer, but they do crash their motorbikes and fall down skiing. We may have to leave them lying there until they get up if want to motivate them to buy a basic Blue Cross policy.
I do agree that P4P is a joke- an excuse for some people to say they are doing something, anything, to look busy. - 7/06/2007 3:50 PM
- Cathy said...
Dr. Schwab, I did read all of this post but I have not read every one of these comments, so if I am repeating someone please forgive me.
Of all the posts I have read pertaining to this topic(and there has been a lot of them) your's makes more sense than any thing else I have seen. Most just whine about it without offering any type solution at all.
I do worry though about a tier system being doable. If we have an NHS for everyone, but at the same time allow private pay for those who want it, won't that just be more of a continuance of what the entire medicaid system has been? Won't the majority of Doc's then just refuse to accept the NHS patients and only see the private pay? Isn't Canada having alot of problem because of that very thing with their NHS? Or, would all Drs. be required to treat NHS patients? I don't know how all this would work, but unless they have to see some, then I think the majority won't.
Also, This is not my personal opinion because thankfully, from reading these medical blogs, I have gotten more educated about this. but, people seem to not have a lot of compassion for Physicians when it comes to their pay and it is because they don't understand exactly where all the money goes.
When we go to the ER and then get a bill for $4,500.00 for very little work done, we sometimes imagine that this money is going to the Dr.s. People think..."Why are they whining about money when I just paid this guy $4,500.00. my opinion is that Dr.s need to begin educating the public about just where all this money goes. the majority of the public do not read medical blogs on a daily basis, and don't understand all this. Until you guys make them understand they are going to think you are paid far more than what you actually are.
Also, what is that OS talking about people dying while waiting for hip replacement? An arthritic or damaged knee or hip is not a terminal illness. How is this happening? If it is because of some other chronic illness they have that caused them to die in the interim, then maybe they should not have been waiting to have joint replacement anyway.
I do think most of what you say is doable. And I absolutely believe an NHS is coming to America. - 7/06/2007 4:38 PM
- Sid Schwab said...
cathy: when I talk about tiers, I don't mean differing levels of compensation for providers; there should be no difference, which would mean there'd be no reason for physicians not to see those patients. I mean -- and it's not entirely fair -- that some things would be covered for those who pay extra, that aren't covered for those who don't. Private rooms. And certain care: maybe national health care won't cover dialysis if you're over 65; but if you want to pay for it, you can get it. Such things are clearly onerous; in Canada, as I understand it, if a thing isn't covered, you can't get it, no matter what (although it seems that may change.) What I'm saying is that -- problematic as it may be -- there ought to be a level of care guaranteed for all, but people who are willing and able to pay more, can get more; until or unless we can get to a point where we control costs and can afford funding everything for everyone. Which is even less likely to happen than having some sort of NHS, I'd say.
Sid, you've overlooked the no-free-lunch reality. You complain that commercial insurers administrative overheads consume premium dollars that could be spent on healthcare. but, you've forgotten that running the Medicare program also involves overheads, something of the order of 20%, that are not included within the Medicare budget but are nonetheless real. Those dollars, too, could be spent on healthcare if they had not been first taken as taxes. In my view, the overheads are a wash. What's important is maintaining freedom of choice.
- Sid Schwab said...
anon: the data I've seen show that in fact medicare administrative costs are far lower than those of insurance companies. Plus, medicare siphons no money to investors, to multimillionaire CEOs; in addition to which, the fact that there are dozens and dozens of companies with differing rules and plans adds hugely to the overheads of the providers having to deal with them.
Sid, this is quite well thought out. But you seem to have a stubborn and completely unwarranted optimism towards the way single payer would be run. In one paragraph you refer to how great single payer will be when providers set priorities and determine how to allot care. Then in the very next paragraph you talk about the utter bureaucratic, pointless idiocy that is P4P without seeming to connect the two!
Single payer will be exactly what P4P is, exactly what JCAHO is, exactly what EMTALA is, exactly what every single government mandate is - completely unworkable mandates issued by faceless bureaucrats who have never touched a patient in their lives. It doesn't matter if the regulation would shut down 75% of America's ERs like one JCAHO issued recently, they'll still do it. And why shouldn't they? It's hardly like it's going to inconvenience them. P4P is an even better example; the measures are almost all irrelevant and everyone acknowledges this. Everyone acknowledges that outcome measures, the only reliable ones, will result in system gaming and hurting sick patients. And yet despite all this, the march of P4P continues unstoppable under the weight of its own bureaucracy.
When or if single payer runs, you may rest assured it will NOT be providers or anything of the sort running it, because that would be COMPLETELY UNPRECEDENTED in the history of American medicine. Let's get real here. - 7/06/2007 7:24 PM
Who will guard the guardians? By which I mean how do we get the hypothetical steering panel of patients and doctors to stay true to their mission? In any single party--oops I mean payor system, the group in power is subject to the complacency of power which tends to corrupt their purpose and stagnate their vision. Accountability . I'm sorry, I think pie(in sky) is the most accurate of the tags for this post.
Frankly, I don't trust doctors being in charge of a big bucket of money.
How about everyone look after themselves. That way, only money that exists in the consumers pockets will get spent.
If you want big bucks get into the NBA not the AMA. - 7/06/2007 7:35 PM
- Sid Schwab said...
anon: I don't disagree. I'm saying this is my solution, not that it's how it will be. If my solution were in place, there would be panels at the top, as I described. I'm not saying that's how it'd be; just that that's how I'd like to see it.
dr bean: I don't disagree with you, either: I've been on boards and panels of insurance companies, and I had to work hard to remind myself that I was there as a physician and not as a company advocate. But I managed, and I assume there are a few among the millions who could, also. Fact is, I have no optimism whatsoever that politicians of either party will ever get to meaningful solutions. Our system no longer is conducive to solutions for any issue, other than finding ways for a given politico to retain power by the most disingenuous means possible. Pie in the sky; no doubt. But we can dream... - 7/06/2007 7:44 PM
- Eric, AKA The Pragmatic Caregiver said...
Here's what kind of decisionmaking we have at the head of the Medicare B carrier for the state of Washington:
In short, the CEO of Noridian got busted for DUI. Yeah, he's a great humanitarian with fantastic judgment. - 7/07/2007 12:23 AM
This kind of rationing of health care might very well help the economic crunch, but who do you suggest should be the types of people who are refused or delayed in this new system, other than the obvious ones like you describe (like the 85 year old who needs dialysis)? I don't think a lot of people would take particularly kindly to the suggestion that some conditions/situations/ages are more "worthy to be treated" than others being built into the system. Of course, I understand that these kinds of decisions are made by insurance companies and such all the time, but it would be more patently obvious under a single-payer system. This nation would have to overhaul its whole line of thinking about access to health care before anything like this would work. Can you picture the righteous indignation when someone found out they were rejected, and another person they perceive as less worthy got their procedure or service? Something strikes me very uneasily about such blatant rationing, even though I know filtering out does happen. And would universal coverage force lowered standards of care and limited access to technology? It seems to be doing so in Canada and on the NHS in Great Britain.
The other problem you mention is a primary one--Americans in general are terrible at being personally responsible for their own health, and that drives up costs for everyone. If we ate better, moved more, and spent less time whining, we'd need less insurance. - 7/07/2007 7:09 AM
- Dr. J. said...
Sid: Here in Canada te reverse discussion is happenning. We have a single payer (sort of) system, and the discussion is around whether we should broaden out private options. One issue I've not seen discussed much is the issue of wealth, health, and entitlement.
In Canada one of the underlying assumptions built into our system is that health care is not a commodity and should be insulated from 'market forces'. It's an issue much in dispute. In general, the assumption means that the type of care you get, the speed at which you get it, and where you get it are not tied to personal (or family) success, achievment or wealth. The idea is that access to healthcare should be universal, and that high quality care should be provided equally for everyone. As an idea, this means that determinents of health (insumuch as they are affected by healthcare) shouldn't be affected by wealth.
There's been a great deal of creep in privitization of elective but important procedures (joint arthroplasty in particular), where individuals pay out of pocket for care at a private hospital, and there-by skip the waiting list.
The essence of this argument is whether wealth should be able to purchase care, or if care should be for all. As a Canadian doctor I understand when patients pay to skip the line up, but I do worry that it does more than confuse the logistics of the system, perhaps it undermines the philosophy of it....
Dr. J. - 7/08/2007 1:39 PM
What a heartfelt discussion here. Unfortunately I'm sure our politicians will collectively throw up their hands in frustration if even 10% of the pros and cons presented in this thread were on their plate. Predictably it will again be pushed to the back burner.
- Sid Schwab said...
Dr J: Ideally, all care would be available to everyone. I'm aware of the issues in Canada, having seen many patients (I'm not far from the border) who chose to pay to come here rather than wait for care. In the US, I think a system that covered everyone equally and perfectly would be intolerably expensive, unless everyone would agree to accept restrictions. And given that such a system is highly unlikely, I think it's also true that a plan that prevented the ability to pay for "extras" would be politically impossible. I'm guessing that if it's ever addressed seriously, after a few failed attempts and after seeing the pricetag, the system will eventually look a lot more like what I suggest than what we have now. My personal plan is to not get sick.
well, here in the land of 'universal' healthcare we seem to be really struggling with the idea that universal should include everybody...
I know that this is probably a very cynical view, but isn't it possible that is we had a public/private system that we could actually free up resources? If the insured could pay their way maybe the public system would actually have room to do more?
I know. I'm impossibly naive.
It's just that living in a community where there are *no* available family physicians/specialists within a 1+ hour radius you start to think that there's something fundamentally wrong.
Preventative healthcare is a great ultimate goal, but how can we possibly get to that point if we are unable to treat emergent issues?
A young friend of ours is sick. It's very likely that he has a serious food allergy. The wait time for an allergist consult is 12 months +. In the meantime his family are trying to eliminate possible causes, but he's making trips to the ER at least once a week for pain control. He's losing weight rapidly, and he's no longer living the life of a normal 9 year old.
How much more is it costing the system to manage his care this way?
This is a situation where both parents are doing their darndest to maintain a healthy situation for their kids, but they have no option but to watch their son get sicker and sicker. They're now in the position of working out how they can liquidate enough assets (i.e. the house) in order to 'buy' healthcare overseas.
Something's going very very wrong. - 7/09/2007 6:43 AM
- Pursey Tuttweiler said...
I found this link through blog contributor Bobby Bittman. It says that tort reform has attracted more specialists to small towns in Texas but has done nothing to improve patient care and has benefited the insurance companies, but not the consumer.
http://www.tortdeform.com/archives/2007/07/the_detrimental_effects_of_cap.html - 7/09/2007 7:27 AM
- Sid Schwab said...
doggerelle: yours is an example of "de facto" rationing, by controlling the number of doctors in various specialties. And your point is a good one, in showing the adverse effects of doing it that way. I agree one solution is to allow for another tier of service. Deciding how much a nation is able/willing to spend, prioritizing it, allowing for "opt out:" it seems nearly impossible, and probably is.
pursey: thanks for that link. I'm going to go read it now. If a national health plan is impossible, tort reform is, I don't know, fantasmagorical? - 7/09/2007 8:11 AM
- DivaJood said...
My argument is, in part, that by eliminating the countless insurers and their enormous overhead (their profits, their executive pay and shareholder dividends -- not to mention countless redundant clerical no-sayers) you could fill the bucket to the same level and have lots left over.
Not just the insurance companies, but the pharmaceutical companies as well - their big-budget advertising is disgusting, and they are constantly inventing diseases and syndroms to sell their drugs at obscene profit margins.
But the bottom line is this: MOST of our tax dollars are being spent killing people in Iraq. Bring that money home, and we'd be able to provide health care for all. - 7/09/2007 12:26 PM
I am a carpenter who works for an idiot; I am self employeed. I love my work and never take care of my health. Why?
I haven't been to a doctor in 20 or so years. Recently got yelled at by a dentist when I had to get a few teeth pulled for having 180/120 bp. Is that high? what do I know.
I have read and appreciated all of Sinclair's "Narnia", and I love your ideal government ideas.
I am pretty dumb, but, I do have government death care already taken care of...my estate will be able to afford a 12 pack, and the city garbage men will deal with the remains...
works for me. - 12/14/2008 1:43 PM
Moving this post to the head of the list, I present a recently expanded sampling of what this blog has been about. Occasional rant aside, i...
In no way is it false modesty to say that physicians are not healers. At best, what we do is to grease the way, to make conditions as favora...
Finally I'm getting around to writing about the gallbladder. Don't know what took me so long, seeing as how, next to hernias it'...
I finished the previous post with the sad story of my patient, illustrating diagnostic difficulties at the fringes of biliary disease. An...


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Gael Greene
Read about Gael Greene by clicking here or contact her via email here.
Steven Richter
Steven Richter, sometimes known as the Road Food Warrior, is my resident carnivorean and took most of the photographs on this site. He is a street photographer, my companion for more than twenty years. And like so many others people we know, he's a critic too these days.
He does digital shots at dinner under pitiful conditions but he has also allowed me to post here some of his travel journalism and also very moving work from his portfolio. All the photographs on this site are protected by copyright.
A retrospective of his work was shown by The Aspen Institute in 2004. His photographs have appeared in Travel and Leisure, Food Arts, Diversions, Saveur, Aspen Magazine, New York magazine, Marie Clare/Italy, Self and elsewhere.
You can see more of his work on line at www.laumont.com. When you come to the homepage Click on "Gallery" on the right side, select artists and then select Steven Richter.
For information please email him at email@example.com.
DUROBI and Göran Billingskog
Göran Billingskog never had any desire to spend intimate time with Elvis. But he shares with Gael Greene and Steven Richter their passion for great food. Goran's list of favorite restaurants in New York is short but will only grow much longer with a teacher like Gael.
Göran also has a passion for great interactive experiences and has worked on large financial web sites like American Express and Allstate, transactional e-commerce solutions like Hotelconxions.com, Tripotel and more.
In creating the Insatiable-Critic.com website, Goran wanted to give readers access to Gael's writing in a simple and stylized magazine format with a focus on Gael's voice and Steven's photography. The website will be dynamically updated with every new entry from Gael. Extensive cross-linking between articles within the website gives the reader the option to jump from article to article and create their own unique reading experience.
Contact Göran Billingskog with comments or questions via email here.
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subset: commoncrawl


text: Offer good while supplies last and cannot be combined with any other promotion. The "Total of All Payments" does not include applicable sales taxes or optional fees and other charges (such as late charges) that you may incur. Pricing applies to new and used/pre-leased items as marked in the store. Product availability may vary by store. Free-rent offers will not reduce total rent or purchase-option amounts. You will not own the merchandise until the total amount necessary to acquire ownership is paid in full or you exercise your early purchase option. Ownership is optional. © 2020 The Premier Companies® All Rights Reserved All stores are independently owned and operated.


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0800 611 8077
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We are a leading provider of classic & vintage bridal transport throughout Inverness and specifically we have helped several couples to arrive in style at Millburn.
It's our passion to provide a timely, relaxing ride for the bride & her entourage on her big day. You will find us friendly but efficient and dependable; we recognise it's the bride's day.
Considering the style of your car is an important part of your wedding day plans. It might be a classic, traditional or even a modern wedding car, but it's not just the colour that's important; you should consider access for the bride and take into account the style of her bridal gown, the width of the passenger doors & the height the car is from the ground.
For children you should check for age restrictions and for bridesmaids check the number of passenger seats.
If the ceremony is a short distance from where the bride departs, you might consider a round-trip for the bridesmaids, otherwise it'll have to be a second car.
The wedding transport should be high on your list once you have booked your ceremony and reception venues. We offer a bespoke service & can assist you in planning your journeys and in matching the right cars to your unique requirements.
First of all, the bride's car will arrive in Millburn about 15 minutes early. It will have the ribbon colour you have specified, be smartly turned out, as will the Chauffeur.
Providing the distance in not too great to the ceremony in Inverness or further afield, if there is not a car booked for the bridesmaids we can transport them or other members of the family to the ceremony. We can do more than one trip, but be thoughtful of the fact that everyone delivered is then waiting for the bride.
When everyone is safely delivered, we wait outside the ceremony as photographs of the bride and groom are generally taken at this point.
Providing the location is local, we can go elsewhere for photographs or, if you are having a reception at another location, photographs can be taken there.
If the ceremony location is the same as the reception location we still recommend a short ride in the wedding car around Inverness; it gives the bride and groom time on their own, the groom a ride in the wedding car that he has hired & the guests a few minutes to prepare for the reception. And if the roof of the car is down on a sunny day, it shows off the bride and groom too!
On request we serve something to drink which we arrange beforehand. This can be provided by yourselves or we can provide it.
Once the photographs are taken, the car will leave and that will be the end of the service.
We rarely do more than one booking in a day, so if things go wrong there is leeway to get things back on track.
We are fully insured for wedding car hire.
We recommend you view any wedding car before making your choice.
Call us to make an appointment or for more information.
it's never too soon to hire the car of your dreams - but unfortunately it can be too late! Check availability & get an instant quote by clicking the green button:


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We are now offering you the opportunity to use our unique banner system to advertise your business.
Our website is one of the most popular in Spain and growing every day. As of September 2011 we are ranked 3000 in Spain 100,000 in the world and have over 88,000 visitors per month - that's more than 1 million people a year. And they could all be looking at your business.
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This is a unique opportunity to advertise on a very large and popular website that is growing every day.
To order your banner TODAY, use the button below.


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Metal Information
Metal Color | White |
Metal Type | 14 Karat |
Metal Weight | 5 Gram |
Width | 2.7 mm |
Height | 6 mm |
Thickness | 1.5 mm |
* The gram weight of the metal varies depending on ring size
* MM measurements are approximate and slightly varies among ring sizes
Diamond information
Diamond Creation Method | Natural, Earth Mined |
Diamond Cut | Very Good |
Center: 1 pear cut diamond weighing 0.35CT. I-J in color, and SI1 in clarity.
Side stones 1: 3 round cut diamonds weighing 0.05CT. I-J in color, and SI1 in clarity.
Side stones 2: 2 round cut diamonds weighing 0.10CT. I-J in color, and SI1 in clarity.
Side stones 3: 10 round cut diamonds weighing 0.15CT. I-J in color, and SI1 in clarity.
Side stones 4: 8 round cut diamonds weighing 0.15CT. I-J in color, and SI1 in clarity.
Enter as many details as possible to best describe how would you like this item to be modified.
Custom Rings, Custom Jewelry, One of a kind rings
Read Why Our Customers Love Us View all
Your online chat response is like receiving face to face retail attention in a professional timely manner. The staff are very knowledgeable and attentative. Keep up the impeccable work.
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IRA Withdrawals that Escape the 10% Tax Penalty
The reason withdrawals from a Traditional Individual Retirement Account (IRA) prior to age 59½ are generally subject to a 10% tax penalty is that policymakers wanted to create a disincentive to use these savings for anything other than retirement.1
Yet, policymakers also recognize that life can present more pressing circumstances that require access to these savings. In appreciation of this, the list of withdrawals that may be taken from a Traditional IRA without incurring a 10% early withdrawal penalty has grown over the years.
Penalty-Free Withdrawals
Outlined below are the circumstances under which individuals may withdraw from an IRA prior to age 59½ without a tax penalty. Ordinary income tax, however, generally is due on such distributions.
- Death — If you die prior to age 59½, the beneficiary(ies) of your IRA may withdraw the assets without penalty. However, if your beneficiary decides to roll it over into his or her IRA, he or she will forfeit this exception.2,3
- Disability — Disability is defined as being unable to engage in any gainful employment because of a mental or physical disability, as determined by a physician.4
- Substantially Equal Periodic Payments — You are permitted to take a series of substantially equal periodic payments and avoid the tax penalty, provided they continue until you turn 59½ or for five years, whichever is later. The calculation of such payments is complicated, and individuals should consider speaking with a qualified tax professional.4
- Home Purchase — You may take up to $10,000 toward the purchase of your first home. (According to the Internal Revenue Service, you also qualify if you have not owned a home in the last two years). This is a lifetime limit.
- Unreimbursed Medical Expenses — This exception covers medical expenses in excess of 7.5% of your adjusted gross income.
- Medical Insurance — This permits the unemployed to pay for medical insurance if they meet specific criteria.
- Higher Education Expenses — Funds may be used to cover higher education expenses for you, your spouse, children, or grandchildren. Only certain institutions and associated expenses are permitted.
- IRS Levy — Funds may be used to pay an IRS levy.
- Active Duty Call-Up — Funds may be used by reservists called up after 9/11/01, and whose withdrawals meet the definition of qualified reservist distributions.
1. In most circumstances, once you reach age 73, you must begin taking required minimum distributions from a Traditional Individual Retirement Account (IRA). You may continue to contribute to a Traditional IRA past age 70½ as long as you meet the earned-income requirement.
2. Distributions to a non-spouse beneficiary are generally required to be distributed by the end of the 10th calendar year following the year of the Individual Retirement Account (IRA) owner's death. The new rule does not require the non-spouse beneficiary to take withdrawals during the 10-year period. But all the money must be withdrawn by the end of the 10th calendar year following the inheritance. A surviving spouse of the IRA owner, disabled or chronically ill individuals, individuals who are not more than 10 years younger than the IRA owner, and a child of the IRA owner who has not reached the age of majority may have other minimum distribution requirements.
3. Investopedia.com, December 24, 2023
4. The information in this material is not intended as tax or legal advice. It may not be used for the purpose of avoiding any federal tax penalties. Federal and state laws and regulations are subject to change, which may have an impact on after-tax investment returns. Please consult legal or tax professionals for specific information regarding your individual situation.
The content is developed from sources believed to be providing accurate information. The information in this material is not intended as tax or legal advice. It may not be used for the purpose of avoiding any federal tax penalties. Please consult legal or tax professionals for specific information regarding your individual situation. This material was developed and produced by FMG Suite to provide information on a topic that may be of interest. FMG Suite is not affiliated with the named broker-dealer, state- or SEC-registered investment advisory firm. The opinions expressed and material provided are for general information, and should not be considered a solicitation for the purchase or sale of any security. Copyright FMG Suite.


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Vintage Harley-Davidson Lake Tahoe Vest
Men's authentic vintage printed Harley-Davidson Lake Tahoe vest. 100% Cotton.
Excellent vintage condition.
Size reads L
Please compare measurements against your favourite fitting garment to ensure accurate fit
Pit to pit: 21.5″
Back of neck to hem: 28.5″
Follow us on Instagram for sneak peaks and offers at Poorboy Boutique 🙂
If you have any questions about the item feel free to drop us a message! x
Pit to pit: 21.5″
Back of neck to hem: 28.5″
We ship all orders via DHL Express
UK – Average 1-3 Working Days
All UK orders placed by 2pm Monday-Friday should be received by you the customer the next day. Orders made Saturday-Sunday should be received on a Tuesday.
A tracking Number will be sent to you via email once your item is ready to be shipped; this allows you to track it all the way to your door.
Our carrier will deliver your parcel between 7am and 9pm. A signature may be required on receipt. If you are not around to accept your parcel, the carrier may leave it with a neighbour, or in a safe place. If this is not applicable the carrier will take it back to the local depot, and leave you a card telling you how you can pick it up.
REST OF THE WORLD – Average 3-14 Working Days
from £15.99
A signature is required on delivery. If you are out a calling card will be left and you will need to arrange collection yourself. If you fail to collect your item within the required time, it will be returned to us and re-dispatched at your cost.
Please note that with all international orders any customs fees and taxes which may be associated with a purchase are the sole responsibility of the customer. If you have any further queries regarding shipping please email [email protected]
At Poorboy we are happy for the customer to return items for an exchange, store credit or a full refund. Poorboy DOES NOT pay any return postage in any circumstance, this must be paid by the customer.
The item must be received by ourselves in the same condition it was sent out, and with external tags still intact where applicable. You can exchange your item for something else featured in our online store, or receive store credit to the value of your original purchase, excluding shipping costs. In the event of a return for full refund, Poorboy must be notifed within 7 days of the completion of the transaction. You will be entitled to a refund from Poorboy which will be paid as soon as possible but in any event within 30 days.
If you cancel your order you must return the goods to us immediately and in the same condition they were sent out in, this is at your own cost. When returning items we will not be held responsible for loss or damage to the goods in return transit and we reserve the right to charge you in the event of loss or damage to the goods.
If the items were made specifically for you or clearly personalised, you will not have any right to cancel the order.
A full refund, excluding delivery costs, will be given within fifteen days of us receiving the goods returned.
Please email [email protected] with the subject title 'RETURN' before you send your item back, stating your invoice number and the reason for wanting to return your item.
Please send all returns to:
VWC – Unit 2, Sovereign Business Park, Bontoft Avenue, HU5 4HF, Hull
The return postage cost is the customers responsibility.
Any issues during return transit are not the responsibility of Poorboy, these issues are to be resolved between the customer and the courier. We recommend returns should be sent by a 'Recorded Delivery' service as this is trackable.
We sell the highest quality vintage clothing around and we have a team specifically grading items for their individualities. Sometimes we do come across pieces that have slight defects but our experienced team feel they are still unique enough to upload and offer to you as our customer.
We spend a lot of time quality checking each piece we upload and any of these signs of wear we record within our detailed descriptions and sometimes photographs where applicable, however on extremely rare occasions some small marks may be missed so please be aware of this when buying from our vintage collection.
Out of stock


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Late night Fish & Chips
Composer, Producer, Logic Pro and Modular synth expert. With a career spanning 4 decades in Electronic Music, Digital Audio and Web Development, I have rather deep experience with all aspects of music, post production and the web. I have done touring, album productions, movie scoring, authoring, documentaries, commercials, direction, mixing, mastering, voiceovers, visuals, site conception and many other different types of audio related projects. But my studio has always been the real centre point for my activities - and still is. It has been continuously developed and refined to an absolute high end, personal electronic sound facility.


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These are our very own removable Thermomix decals.
Let's face it, white is so boring! Decorate your TM6, TM5 or TM31 to suit your personality!
Hi-Res image laminated with a clear protective top layer to allow cleaning whilst not damaging the print.
Easy to apply and removes perfectly clean leaving absolutely no glue residue on your beloved machine.Does not void warranty and comes with application instructions.
Made here in South Australia.
Floral 65


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The Take 5 Oil Change located in Milton recommends you change your oil every 5,000 kilometers or 3 months, whichever comes first. (Follow your owner's manual recommendations) Proper oil maintenance will help extend the life of your vehicle. Even if you do not drive often, the engine oil could get contaminated as a result of accumulated moisture. Contaminants are whipped into the oil as it runs through your engine. Neglected oil will eventually turn these contaminants into sludge. Sludge could eventually cause engine failure.
Not only does the oil become dirty but the additives in oil (which play such a vital part of its performance) will begin to break down and no longer perform. Consider your motor oil the blood of your engine. It plays a vital part in your engine's system. However, unlike the blood in your body, it needs to be replaced regularly.
During our multipart oil change service, the technicians at Take 5 Oil Change located at 900 Steeles Ave. E. will replace all of the engine's oil, the oil filter as well as check and replenish all vital under the hood fluids to the recommended level with the exception of brake fluid. Along with checking your engine's air filter, inspecting your wiper blades, adjusting the tires to the recommended pressure, and cleaning your windshield, all this is done in just a few short minutes.
Our certified, friendly technicians at Take 5 Oil Change in Milton, will offer you a complimentary beverage, provide you with a "next service due" sticker and reset your maintenance indicator light (where applicable).
Location Hours: closed now
Mon-Fri: 8:00 AM - 7:00 PM
Sat: 8:00 AM - 7:00 PM
Sun: 9:00 AM - 5:00 PM
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Use our personalized Baby Shower About To Pop Gold Glitter candy jars as a stylish way to give some sweet treats to your guests. These unique Baby Shower Jars measure 2 ½â tall when standing upright and almost 1 ½â wide. The candy jar favors are made of glass and feature a unique depression or flat area on the belly which allows you to sit them at an angle so that the customized label can be seen.
You can personalize your Baby Shower jars with up to three (3) lines of text and you can choose from a large selection of text fonts and colors with our easy to use online ordering system.
Our Baby Shower Jars are available in all of our exclusive themes and we also offer a large selection of other matching items such as Baby Shower favors, invitations, thank you notes, stickers and labels so you can truly throw a great Baby Shower event!
If you are wondering what you can put in our personalized Baby Shower About To Pop Gold Glitter candy jars here are some suggestions: 75 Jelly Beans, 80 m & m size candy covered chocolates or 4 liquid ounces.
Important things to know about our Baby Shower About To Pop Gold Glitter candy Jars:
Except during severe weather conditions or other natural disasters, guaranteed delivery means if we miss our delivery date we will refund the shipping cost.
Guaranteed delivery dates only apply to orders shipping within the 48 contiguous United States. Orders shipping to Alaska, U.S. territories, or international destinations may take up to an additional 5 business days.
Flat rate shipping charges are calculated based on pre-tax and pre-discount merchandise totals.
Flat rate shipping charges only apply to orders shipping within the 48 contiguous United States.
For orders shipping to Alaska, Hawaii, U.S. territories or international destinations, shipping rates can be calculated during checkout.


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Campaign reporters spend a lot of time pointing at color-coded electoral maps like the one below, showing which states voted for Republican John McCain (in red) and Democrat Barack Obama (in blue) in 2008.
But these maps lie — visually speaking.
Red appears to be the clear winner, dominating a vast swath from the South to the Rockies. It's all geographically accurate, but electorally skewed. For example, Montana (three electoral votes) dwarfs Massachusetts (which had 12 electoral votes in 2008).
To fix this problem, some political cartographers have resized the states based on their electoral vote tally.
In this map, the influence of the Northeast is a bit more apparent, and the stature of the Mountain West has diminished. We've shaded the states based on their popular vote results in 2008. States that were split 50-50 are purple.
But this map still doesn't accurately convey which states are most important in this election. What would this map look like if states were scaled based on the outside money (not even including the massive ad spending by the campaigns of President Obama and Mitt Romney themselves) coming into the presidential race for political ads?
We looked at ad spending on the presidential race from April 10 to Oct. 10, based on data from Kantar Media. The millions of dollars spent by superPACs and other outside groups send a clear message: There are really only 12 states in this presidential election. It's no surprise that they are all pretty purple.
There is another way to think about this spending — how much is being spent on political ads by these groups per voting-age adult?
Here, Nevada and New Hampshire take the lead. Though they don't have large populations, both states are seeing millions of dollars invested by outside groups on ads related to the presidential contest. That works out to more than $5 per adult.
So if you're lucky enough to live in the Granite State, congratulations. In some ways, your vote is a thousand times more valuable than the votes of your neighbors in Vermont.
Copyright 2021 NPR. To see more, visit https://www.npr.org.


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Time to Improve Your Health in Merritt Island
Time to Improve Your Health in Merritt Island
Every year hundreds, if not thousands of people suffer some type of lower back injury. This often requires a visit to their Merritt Island chiropractor as a result of gardening or doing some other type of yard work. This happens a lot in the spring when people are anxious to get outside and tend to their yards after months of being penned indoors by the winter season.
It is relatively easy to injure your back, especially if you are moving heavy objects around the yard. While good chiropractic care is always one of the first things you should do after receiving such an injury, you also want to consider the fact that chiropractic care, which occurs on a fairly regular basis, may help to curb some of these injuries in the first place as does following some common safety precautions when you are working in your yard.
There are a number of tips that can help you when it comes to preventing back injuries while you are working in your yard. Perhaps one of the most important things to remember is that in most cases, the more fit you are the less likely you are to suffer an injury of this type. Fitness is a good idea in any case and this is especially true when you are performing any type of rigorous physical activity. Good muscle tone and flexibility will go a long way toward helping you stay healthy and free from back injuries that can be very painful.
In addition, you always want to lift properly. Always lift with your knees and keep your feet in front of you approximately a shoulder length apart. Whatever you do, never lift with your back. This is one of the primary reasons that people receive back injuries in the first place. Another thing you can do to reduce your chances of injuring your back is to use tools that work well for you. If you are an individual with a smaller build, you need to use smaller tools and try not to move things that are too heavy without help.
Of course, if you do feel tightness in your back, or you have had an especially hard day, you can typically relieve much of the tension by icing the muscles appropriately. If you prefer, you may want to alternate ice and heat in order to reduce inflammation and then relax the muscles. Ensure that you do not apply ice directly to the skin and that you use caution when applying heat.
It is always a good idea to visit your chiropractor on a regular basis even if you are not currently experiencing any problems. This can prevent you from suffering a back injury or some other type of injury while you are working in your yard. In the event that you do suffer an injury visiting Chiropractic Health Clinic in Merritt Island can be an integral part of the recovery process. Working in your yard and getting ready for spring is something that most people enjoy, but it is also something that you should do carefully in order to ensure that you do not injure yourself. Be safe and contact us with any questions you may have.
8:00am - 12:00pm
3:00pm - 6:00pm
By Appointment
8:00am - 12:00pm
3:00pm - 6:00pm
8:00am - 12:00pm
3:00pm - 6:00pm
By Appointment
Chiropractic Health Clinic
110 North Tropical Trail
Merritt Island, FL 32953
(321) 459-9400


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A Trip to New Mexico in 1955
Joe was a teacher, so he had the whole summer off from school too when I was a kid. Before he retired in 1960, we would travel around the Western United States for three to four weeks every year. He … Continue reading →
Posted in baseball, Childhood, Dodgers, El Capitan, Joseph Martin Cunningham, L.A. Angels, Los Angeles, New Mexico, Pacific Coast League, Santa Fe Railroad, trains, Travel, Uncategorized, World Series, Yankees
Tagged .22 caliber bullet shells, 1955, 1956, airedale, Albuquerque, archaeological excavation, archaeology, Arizona, Aunt Lorna, Barry Cunningham, Barstow, baseball, Brooklyn Dodgers, California, candlemakers, ceilings, clock radio, decals, desert, dog, Don Larsen, El Capitan train, Flagstaff, glassmakers, Glendale Station, high level dome car, Jackie Robinson, Joseph Cunningham, La Case de Colores, La Iglesia de Nuestra Señora Reina de Los Angeles, Las Vegas NM, Lorna Johnson, Los Angeles, Los Angeles Angels (Pacific Coast League), Los Angeles Plaza, Los Angeles Union Station, luggage, Milky Way, Mission Revival, Mojave, Motorola, Needles, New Mexico, New York Yankees, Old Plaza Church, Olvera Street, Pacific Coast League, perfect game, Queen of Angels Hospital, ranch, Rancho de Taos, San Francisco de Asis Mission Church, Santa Fe Railroad, Santa Fe Warbonnet design, shoeshine boy, sick, sopaipillas, sopapillas, spittoons, Springer, stainless steel, starry night, stars, stealing home, Steve Bilko, Taos, train, World Series, Yellow Cab, Yuma
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The new SRAM DUB crank standard, built on a 28.99mm spindle, allows for a more contamination-resistant BB design, while retaining the ultra-efficient & long-lasting qualities CeramicSpeed Bottom Brackets are known for.
With an integrated dust cover for all models, the snug & secure fit not only fully protects the face of the bearing, but also delivers exceptional performance without any sacrifices. CeramicSpeed hand-built bearings carry the load from crank to frame with unparalleled durability & efficiency.
The SRAM DUB crank spindle requires the bearing contact points to be in a set and designated width, and all CeramicSpeed bottom Bracket options perfectly match the bearing placement on the crank spindle with the required frame interface for nearly any model of bike. Without the use of unnecessary adapters or spacers, a quiet & stable platform is ensured throughout the life of the product.
The PF30A for SRAM DUB Road comes in two versions. The first version uses our low-drag, long-life Standard Bearing with hardened-steel races and our super-round CeramicSpeed balls. The second version uses our Coated Bearing, which uses those same balls installed on coated, hardened-steel races for longer life and less bearing drag.
Compatible with:
- Frame: PF30A
- Opening diameter: 46mm
- Shell width: 73mm
In the box:
- 2 cups with CeramicSpeed Bearings installed
- 2 dust covers
- Spacer-tube
- 4 x 1mm spacers
- 2 x 3mm spacers
- 10 ml syringe of CeramicSpeed All Round Grease
- Sticker sheet
Part Numbers
Option | UPC | MPN | Store SKU |
Black / PF30A / Standard / DUB / 73mm | 05711050065080 | 106757 | 210000018491 |


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"Been using this card since Oct 2009 and it has always worked without fail. Best deal anywhere for calling cell phones in Panama and also landlines. Money is deposited instantly to your account! Always clear,always able to connect, it lets you know how much time you have left when you call."
"Thank You for the prompt attention:


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The city of Kenai is in many ways the heart of the Kenai Peninsula, both economically and because the massive Kenai River draws thousands of Alaskans from all over the state every summer for salmon fishing.
Read Top 6 Things to Do in Kenai.
Kenai is the largest community on the Kenai Peninsula with a population of around 7,800. The city sits on a low rise overlooking the mouth of the Kenai River. To the west, majestic views of the Alaska Range and three active volcanoes (Mount Spurr, Mount Iliamna, and Mount Redoubt) make for a dramatic backdrop. Located on the western side of the Kenai Peninsula, the town of Kenai is accessible by road, just off the Sterling Highway, 160 miles from Anchorage and 80 miles from Homer.
The main reason most visitors come to Kenai is for the world-class salmon fishing in the lower Kenai River and at its mouth. King salmon, red salmon (also called sockeye salmon), silver salmon (coho), and pink salmon spawn up the river and are caught by anglers each summer. The Kenai River was responsible for producing the world-record-holding king salmon, which weighed in at more than 97 pounds. Most charter fishing captains based in Kenai focus on the Kenai River, offering clients float trips that include casting for four different species of salmon, with the primary target being the giant Kenai king salmon.
Visitors to Kenai also enjoy scanning the waters offshore for beluga whales from the edge of the bluff at Beluga Whale Lookout. The observation area overlooks the mouth of the Kenai River, and in late spring and early summer, belugas are often seen riding the incoming tides to feed on salmon. The lookout also provides a good view of the mouth of the Kenai River, which is hopping with fishing activity in the summer, and the volcanoes on the west side of Cook Inlet.
Old Town Kenai is home to a collection of historical buildings that tell the story of the area's rich history. Start at the Kenai Visitor and Cultural Center, a source of local information and an attraction unto itself, with historical exhibits and walking maps of Old Town. The historical exhibits highlight the city's Russian heritage, offshore drilling, natural history, and Alaska Native artwork.
In 1867, the U.S. Army built Fort Kenay, a series of barracks where more than 100 soldiers were stationed. Today, visitors can see a replica of the fort in Old Town that was reconstructed as part of the Alaska Centennial in 1967. Across from Fort Kenay is the ornate Holy Assumption of the Virgin Mary Russian Orthodox Church. The white-clapboard structure topped with three blue onion domes was built in 1895. It is the oldest Orthodox church on mainland Alaska and designated as a National Historic Landmark, one of only 48 in Alaska. Just west of the church is St Nicholas Chapel. The small chapel was built in 1906 over the burial site of Father Igumen Nicolai, Kenai's first resident priest. Additional historical buildings, including several homesteader cabins dating back to the early 1900s, can be seen in Old Town.
Outdoor recreation enthusiasts will find lots of activities in the Kenai area, including hiking, biking, boating, birding, and wildlife viewing. The nearby Captain Cook State Recreation Area is located on the shores of the Cook Inlet and is a peaceful spot for beachcombing, picnicking, and birding. The Kenai National Wildlife Refuge encompasses 2 million acres of mountains, forests, wetlands, and lakes, and is a popular destination for hiking, canoeing, fishing, wildlife viewing, and camping.
Kenai offers the only full service 18-hole golf course on the Kenai Peninsula, with a driving range, pro shop, clinics, and power cart rentals. The golf course is open for golfing late into the evening in summer and for cross-country skiing in winter. If disc golf is more your thing, the City of Kenai maintains an 18-hole disc golf course that is free and open to the public year-round.
The North Peninsula Recreation Center is a year-round recreation area that includes a large indoor swimming pool with 136-foot water slide, racquetball courts, skateboard park, climbing wall, running-fitness trails (summer), cross-country skiing and ice hockey (winter), multipurpose fields, teen center, and children's programs.
Summer is the peak time to visit Kenai, but there are plenty of outdoor recreation opportunities to take advantage of in winter. Locals and visitors alike enjoy cross country skiing, ice fishing, snowmobiling, fat tire biking, ice skating, and hockey.
For those interested in fishing, Kenai is home to several fishing lodges that include accommodations, meals, and fishing charters. A wide variety of hotels, inns, motels, lodges, B&Bs, hostels, and cabins can be found in Kenai, with many featuring stunning vistas of the Cook Inlet or peaceful views of the Kenai River. There are two RV parks in town and lots of campgrounds in the many parks and public lands in the surrounding area.
The Kenai River's legendary salmon is the reason Kenai is one of the oldest continuously inhabited European settlements in Alaska. Before contact with the Western world, Dena'ina Athabascans had a permanent village of more than 1,000 in the area. Russians were the first non-Native people to settle in the area, in 1741, and later established a fortified trading post, Fort St. Nicholas, which included the first Russian Orthodox Church on mainland Alaska. Modern Kenai took shape in the 1950s, and specifically in 1957, when the first major oil strike in Alaska was made at Swanson River, 20 miles northeast of Kenai.
Explore more in the Kenai Peninsula.
Plan Your Trip
ATTENTION PHOTOGRAPHERS: WE LOVE BEARS AND ANIMALS! This is the tour for you. We are focused (pun intended) on wildlife. Spectacular small-group...
Explore the vastness of the Chugach National Forest during this 1 1/2 hour tour. Your bush pilot will soar over mountain lakes and valleys full...
Local Climate & Weather
For Alaska's day-to-day weather, it's best to plan for a bit of everything. Learn more about weather in this area.
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July 22nd
Pick a lesson and time.
Important Lesson Info:
1. Our lessons take place in a 4-5 hour window each day around the low tide. Because we make our schedule months in advance based on future tide projections, exact lesson times are subject to slight changes based around the tide and conditions for a given day. We will always call or text you the evening before the lesson to confirm the exact time. We bring this to your attention so that you can be aware while planning other activities around your lesson.
2. You can book the Ocean Classroom, Private, Private Groups, and the Graduate lessons online. Make sure to use the discount code, "thegraduate" at the checkout to apply the discount. If you would like to book a custom package or have any questions at all please call us at (508)-514-1555. We can always book you over the phone!
3. Cancellation policy: We have a zero refund policy. We will contact you if the weather and/or waves are unsafe and move the lesson to a later date. If the conditions or the client's schedule does not allow for the lesson to run within your time on the Cape, we will apply a future credit.