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Health Care Reform: Center Stage 2012
A Deloitte series on making America stronger
Health care impacts every citizen, and is complicated, fragmented, and expensive. Deloitte's surveys illustrate the challenges of changing expectations to support health care system transformation.
Health care reform is center stage in 2012—prominent in the public consciousness, thanks to constant political and legislative skirmishes over the future of the Affordable Care Act (ACA). With respect to the ACA, 2012 through 2014 are seminal, "make or break" years for the health care industry. Many factors are in play, including the Supreme Court decision regarding the ACA's future and other big-picture, "battleground" issues such as the expiration of the Bush-era tax cuts, sluggish economic recovery, wavering unemployment, and deficit reduction. All of these are occurring within the context of a Presidential election year and lame-duck session of Congress, and potential shifts in the membership and balance of influence in both houses. Irrespective of what happens as these factors and their ensuing ripple effects play out on the national stage, the basic drivers of health care reform (which pre-date the ACA) remain: an unsustainable cost structure and relentless increase in costs; the need for basic minimum access to affordable health care for those currently without it; and the need for a quantum leap in quality and comprehensive systemic reform.
In addition to government, which serves as regulator, provider, and payer, three key players in the health care sector are those who use the system, those who provide the services, and those who pay for them: of interest in this monograph are consumers, physicians, and employers. All three parties approach health care from unique perspectives – seeing value, quality, costs, and system organization through very different lenses. Their views of the health care system and health care reform are critically important to guide and inform the policy makers who oversee its functions.
Over the course of the last year, Deloitte has surveyed thousands of Americans – consumers, physicians, and employers – about their opinions of health care reform. This monograph brings together unique, data-driven insights on these stakeholders' perspectives, gathered through three research studies conducted by the Deloitte Center for Health Solutions: the 2012 Survey of Health Care Consumers in the United States; Physician Perspectives about Health Care Reform and the Future of Medicine (2011) and the Deloitte Employer Survey (2012). Occasional data are also drawn from the 2011 Survey of Health Care Consumers in the United States.
Much has been written and more said about modernizing and recalibrating the U.S. health care system, making it more efficient and effective through health care reform. At the end of the day, success will be judged on whether reform has achieved its broad aims of enhancing the patient experience, improving population health, and reducing per capita costs.2 Managing costs is, perhaps, the biggest challenge; a less expensive system with a more measured and sustainable cost structure may be the true barometer of success.
In 2010, health care consumed 17.6 percent of the U.S. gross domestic product (GDP), or $2.6 trillion in health care expenditures;3 as widely noted, the United States consistently spends more on health care per capita than do all other developed countries.4 Health care costs hover just under $8,500 per capita5 and are expected to increase at an average annual growth rate of 5.8 percent for the next decade.6 This annual growth is anticipated to exceed that of the economy by 1.1 percentage points; by 2020, national health spending is expected to reach 19.8 percent of GDP, at $4.6 trillion in health care expenditures7 (see figure 1).
Consumption of health care goods and services has slowed in recent years, with historically low and slower spending growth during 2009 and 2010 attributed to the impact of the 2007–2009 recession on the health care industry and consumer wariness in the face of financial uncertainty. The federal government's share of financing the health care system grew during this period as household, employer, state, and local government shares decreased. Adding complexity to the situation, an estimated 32 million individuals will be required to hold a minimum level of health insurance beginning January 1, 2014, as a direct outcome of the ACA. The Deloitte model, The Impact of Health Reform on Health Insurance Coverage: Projection Scenarios Over 10 Years,8 assesses the effects of key economic, behavioral, political, and strategic variables on insurance coverage under the ACA, and produces a ten-year annual projection of market configuration in terms of the number of insured and uninsured.
Figure 1: National health expenditures
Health expenditures
- 23% of the current federal budget and 21% of the average state budget
- http://www.usgovernmentspending.com/health_care_budget_2012_1.html, accessed April 2012
- 19% of discretionary spending in the average household
- Bureau of Economic Analysis http://www.bea.gov, accessed April 2012
- Health costs increased 3.9% in 2010; 3.8% in 2009
- Martin et al. Health Affairs, 31, no.1 (2012):208-219
- Over the past 30 years, health care costs (national health expenditures per capita) have exceeded the GDPper capita by an average 2.25% year on year
- Kaiser Family Foundation, http://facts.kff.org/chart.aspx?ch=855, accessed April 2012
Long-term sustainability government finances
The long-term sustainability of government finances is expected to be considerably impacted unless efforts are made to tackle spending for health care and social entitlement programs.9 Standard and Poor's estimate that age-related government spending (health care, pensions, long-term care and unemployment benefits) will rise from 10.8 percent of GDP in 2010 to 18.5 percent of GDP in 2050. The citation remains the same.10 Furthermore, S&P projects age-related health care expenditures to rise from 4.5 percent of GDP in 2010 to 5.7 percent in 2020, and for long-term care expenditures to rise from 1.0 percent to 1.2 percent of GDP over the same time period.11 The Congressional Budget Office (CBO) estimates that the federal budget will be increasingly strained by spending on the government's health care and entitlement programs, with outlays expected to increase more rapidly than nominal GDP, at around 7 percent a year between 2012 and 2021.12 An aging population and rising health care costs are expected to continue to significantly impact the federal budget, particularly if revenues follow the historical pattern, forcing federal debt to reach "unsupportable levels."13 Federal outlays for Medicare, Medicaid, and other mandatory health programs are estimated to equal 5.5 percent of GDP in 2012. The CBO's baseline projection for these programs estimates more than doubling in spending, rising by an average 8 percent per year to 2022 and reaching 7.3 percent of GDP in 2022. Half of this growth is attributed to Medicare, one-third to Medicaid, and the remainder to subsidies for forthcoming health insurance exchanges.14
Hidden costs of health care
In 2011, Deloitte estimated that spending on health care outside of the National Health Expenditure Accounts (NHEA) for such items as supervisory care for others, complementary and alternative medicine, vitamins, supplements, nutritional products, and so on, would account for an additional $363 billion, or 14.7 percent more than that reported in the NHEA accounts.15 Consumers' personal consumption expenditure for health care is estimated to be the second-highest household expense, after housing/utilities. Health care expenses are of concern to consumers: In Deloitte's most recent health care consumer survey (2012), only 17 percent of consumers feel that their household is sufficiently prepared to handle future health care costs, and nearly one-third (31 percent) report that, compared to the previous year, their household's health care spending increased as a proportion of their household's total consumption.
Figure 2: Health care employment, April 2011 to April 2012
Health care sector employment continues to grow
Reflecting increased spending, the U.S. health care sector has been a source of consistent and continuous job growth. One-third of the 30 fastest-growing occupations are in health care;16 post-recession, health care continues to add jobs. In April 2012, 19,000 new health care jobs were added, reflecting the upward employment trend in the industry, which gained 316,000 jobs between April 2011 and April 2012 (see figure 2).17 Health care industry employment rose from 8.7 percent of the total U.S. civilian workforce in 1998 to 10.5 percent in 2008, and is projected to increase to 11.9 percent, or 19.8 million, by 2018.18
Health care is intensely personal
Consistent with other studies on consumer engagement in health care,19 Deloitte's annual health care consumer survey, conducted 2008–2012, has found that consumers are satisfied with the care that they personally receive but unhappy with the health care system as a whole. Consumers are connected with the traditional health care system, with most having a primary care provider and at least one interaction with the system in the last 12 months. Over half of consumers currently use prescription medications, and nearly one-third are using over-the-counter medications.20 From physicians' perspective, the health care system is performing solidly rather than well. Many express disappointment with a perceived lack of inclusion in the health care reform process. Many physicians believe reform to be detrimental to the future of medicine, and expect that it will spur an exodus from clinical practice and be a deterrent to those considering medicine as a career.21 Employers, concerned about their bottom line, are particularly critical of the cost of the health care system but overwhelmingly supportive of the value of employer-sponsored health insurance, with over eight in 10 employers offering health benefits to attract and retain good employees and to improve employee morale and satisfaction.
Personal and cultural values serve as filters through which individuals perceive and value health care. A broad spectrum of such things as core beliefs about health care,22,23 and the degree of trust in institutions, government, and "science"24 may well color how the public views efforts to realign the structure, conduct, and performance of the U.S. health care system. Do Americans have the health care system that they want, as some suggest?25 How well is health care reform understood, and to what extent is there underlying support for the ACA?
Many of the ACA's proposed changes and implementation dates will take place in 2013 and 2014. What do consumers, physicians, and employers think about health care reform? To what extent do these groups feel included or engaged in the reform conversation? How do they view the performance of the U.S. health care system?
Health care reform shifts the goal posts for many stakeholders; its success depends, to a large degree, upon convincing system participants to play ball. It is, therefore, appropriate that this monograph, bringing together data from Deloitte's three surveys, explores how participants view and respond to various aspects of reform.
The Deloitte Studies
Health Care Consumer Survey
Since 2008, the Deloitte Center for Health Solutions has annually polled a nationally representative sample of the U.S. adult population (up to 4,000 U.S. consumers) about their interest in and ability to operate in a consumer health care market. These online surveys have queried adults in varied health status, income, and insurance cohorts to gauge the degree to which consumers are prepared to engage the health care system as "patients" or "consumers." Results are weighted to ensure proportional representation to the nation's population with respect to age, gender, income, race/ethnicity, and geography.
Physician Survey
During summer 2011, the Deloitte Center for Health Solutions surveyed physicians on a range of topics, from their opinions of health care reform to their attitudes about the practice of medicine. Drawing from a random sample of primary care physicians and specialists from the American Medical Association's (AMA) master file of physicians, 501 physicians completed a survey administered online. Results were weighted by practice, gender, region, and specialty to reflect the national distribution of physicians in the AMA master file.
Employer Survey
560 non-government firms with 50 or more workers and offering health benefits to employees completed an online survey between November 2011 and March 2012. The survey included questions on topics covering various issues related to employer health benefits and health care reform. Results were weighted to match firm count distributions in the U.S. Census Bureau's 2009 Statistics of U.S. Businesses by firm size, principal industry, and region, and were further adjusted to reflect firms offering health benefits. Results were separately weighted to reflect national worker representativeness.
Context: Views of the U.S. health care system
While many players in the U.S. health care system have concerns about ACA, they also hold deep concerns about the system's overall performance.
Views on overall performance: System report card
The majority of consumers feel that the U.S. health care system is complicated (three in four in 2011 said they did not have a strong understanding of how the system works) and may not be the best in the world (three in four believe other systems may work better). Satisfaction with the system is low—22 percent report feeling satisfied with the system's overall performance in 2012—but may be improving (up from 16 percent in 2011).
In 2012, consumers' report card grades for the system have improved over previous years, with positive opinion (a grade of "A" or "B") rising from 20 percent in 2009 to 34 percent in 2012. This is similar to the grades given to the system by both physicians (35 percent) and employers (35 percent). However, 63 percent of consumers grade the system as performing poorly or failing (a grade of "C", "D," or "F"), as do physicians (65 percent) and employers (65 percent) (see figure 3).
Figure 3: System performance, cost drivers, and health care reform
Executives closest to the health care system, such as those responsible for health benefits programs, are often the least positive about the system's performance, with only 15 percent of benefits administrators, 21 percent of chief Human Resources officers, and 27 percent of health benefits executives grading the system performance positively. Office managers responsible for benefits view the system most negatively, with 41 percent grading it a "D" or "F."
Waste and cost in the health care system
Increasing perceptions of waste and lack of value may be contributing to dissatisfaction with the U.S. health care system: In 2012, 62 percent of consumers say they believe that 50 percent or more of the dollars spent on health care are wasted, and only 25 percent feel that the best value is obtained for the money that is spent. This is in contrast to consumers' beliefs in previous years, where consistently around 50 percent of consumers said they felt that between 50 percent and 100 percent of all spending on health care in the U.S. is wasted. Consumers see system strengths in medical technology, innovative treatments, and services (61 percent) and meeting the needs of the insured (54 percent), whereas the system is considered to fail (rating performance as a "D" or "F") those without insurance (53 percent) and to offer poor value for money spent on health care (44 percent). In contrast, 67 percent of employers consider the system to be failing with respect to the cost of care (a grade of "D" or "F"). Employers feel that the health care system performs well (a grade of "A" or "B") in achieving such things as medical innovation (69 percent) and access to services (53 percent); however, they believe that the insurance and payment systems are difficult to understand (55 percent) and navigate (29 percent) (a grade of "D" or "F").
Elements of the health care system that concerned consumers in 2011 also worry them in 2012. Consumers are slightly less concerned than in previous years about the impact of the cost of prescription medications on overall system expenditures (48 percent in 2012 versus 54 percent in 2011), costs of hospital care (59 percent in 2012 versus 68 percent in 2011), and insurance administrative costs (52 percent in 2012 versus 57 percent in 2011). Slightly less than half of consumers (46 percent) believe that consumer behavior (such as unhealthy lifestyles that contribute to obesity) has a "major" influence on overall costs. More commonly, consumers believe that hospital costs (59 percent), fraud (55 percent) and insurance company administrative costs (52 percent) are major cost drivers, and nearly as many point to the influence of defensive medicine (43 percent), government regulation (41 percent), and payment incentives that reward volume instead of performance (37 percent). In contrast, 70 percent of physicians and 67 percent of employers view consumer behavior as a major contributor to health system costs. Eighty percent of employers point to hospital costs and over six in 10 employers see prescription drug costs (66 percent), insurance company administrative costs (62 percent), and government regulation (60 percent) as being major drivers of cost in the health care system. Physicians also see defensive medicine (59 percent) and insurance company administrative costs (57 percent) as major cost drivers (see figure 4).
Figure 4: Consumer, physician, and employer views on cost drivers in the U.S. health care system ("major influences")
Views on health reform
A "good start" or a "step in the wrong direction"?
Two years into the implementation of the ACA, opinion remains divided on the merits of health care reform. As a whole, consumers are mildly positive to somewhat ambivalent, physicians neutral, and employers negative about the ACA. Consumers hold a less favorable view about health care reform in 2012 than they did in 2011 and evidence stronger feelings of uncertainty. Half of consumers felt positively about health reform in 2011 (50 percent) whereas only 38 percent feel this way in 2012. Many more consumers are uncertain about reform in 2012, either not knowing or expressing no opinion (34 percent in 2012 versus 21 percent in 2011). Overall, physicians are split as to whether health care reform is a "good start" (44 percent) or a "step in the wrong direction" (44 percent), and compared with consumers and physicians, employers are much more inclined to view reform in a negative light, with almost six in 10 seeing it as a "step in the wrong direction" as compared with three in 10 employers viewing health reform as a "good start'' (see figure 5).
Greater consumer uncertainty about health care reform is apparent, irrespective of age, gender, insurance status, income, or location. In both 2011 and 2012, seniors (born 1900–1945) have tended to have a more negative view of the reform law than younger generations. The percentage of consumers of all generations with feelings that health care reform is a "step in the wrong direction" has remained relatively constant; however, what has changed is that positive views of reform have declined substantially in all generational groups, shifting towards "don't know/no opinion." Women are more uncertain about health care reform than men (38 percent versus 29 percent) but less likely than men to feel negatively about reform (26 percent versus 32 percent).
Greater consumer uncertainty about health care reform is apparent, irrespective of age, gender, insurance status, income, or location.
Positive feelings about the reform law held by uninsured persons, a group that stands to benefit from provisions of the ACA, has dropped from 55 percent in 2011 to 37 percent in 2012. Favorable views held by those with insurance also have declined, from 49 percent in 2011 to 38 percent in 2012. In 2012, significantly more consumers with insurance (30 percent) see health reform as a "step in the wrong" direction as compared with those without insurance (23 percent). Again, ambivalence about health care reform is marked, with 32 percent of people with insurance and 40 percent of the uninsured being uncertain or expressing no opinion (see figure 5).
Figure 5: Consumer views on the merits of health care reform*
Physicians appear to be "hedging their bets" about health care reform. While many physicians (59 percent) expect an exodus from the profession due to reform, over half (55 percent) are adopting a "wait and see" approach, thinking that reform might fall apart, and don't plan to make changes to the way they practice medicine. Most physicians (82 percent) are pessimistic about the future of medicine as a result of reform, and many think that would-be physicians will consider other options rather than choosing medicine as a career (69 percent). Fifty-four percent of all physicians (63 percent of surgeons) hope to retire before making any reform-driven changes to the way they practice medicine today, particularly physicians aged 50 years and older.
Most physicians (82 percent) are pessimistic about the future of medicine as a result of reform, and many think that would-be physicians will consider other options rather than choosing medicine as a career (69 percent).
As with consumers, more male physicians consider health care reform in a negative light (47 percent versus 37 percent females) and females tend to be more undecided than males (17 percent versus 10 percent). Opinion is sharply divided among the broader categories of medical practice, with more primary care practitioners (PCPs) (45 percent) and non-surgical specialists (53 percent) holding positive views about reform than their surgical specialist colleagues (28 percent). Surgical specialists (60 percent) are very negative about reform as compared with PCPs (39 percent) and non-surgical specialists (36 percent).
Employer views varied; larger companies are more likely to define the law as a "good start" than smaller ones—for example, in Deloitte's employer survey, 39 percent of mid-sized firms with 1,000 to 2,499 employees say it is a "good start," compared with 25 percent of the smallest firms (50–100 employees). Nevertheless, over half (57 percent) of very large employers (2,500+ employees) view health care reform as a "step in the wrong direction." In addition, company decision makers feel negatively towards health care reform (65 percent) rather than positively (28 percent). Those managing companies' health care benefits tend to view reform more positively; four in 10 (41 percent) of executives responsible for health programs and 38 percent of CHROs see it as a "good start," whereas 72 percent of owner/CEO/presidents and 64 percent of CFOs say that health reform is a "step in the wrong direction."
Understanding of and preparedness for health care reform
Consumers are apprehensive, physicians feel left out, and employers are unprepared for health care reform.
In 2011, 44 percent of consumers anticipated that the health care reform law would bring about improvements for consumers within the next five years; 24 percent believed that improvements would take more than five years; and one in three (31 percent) doubted that improvements for consumers would ever happen. Older generations were most skeptical about the eventual success of health care reform, with nearly two in five seniors (born 1900–1945) believing that improvements would never come, and more than one in three boomers (born 1946–1964) echoing that sentiment.
In 2011, consumers were almost evenly split on whether the government should require individuals to carry health insurance. Nearly 40 percent said the government should require every individual in the country to have health insurance; slightly more than 40 percent opposed the individual mandate. The remaining 20 percent were unsure. These findings echoed consumer views in 2010 (42 percent "yes," 38 percent "no," and 20 percent "unsure"). Uninsured consumers were less likely to support an individual mandate than insured consumers (30 percent versus 41 percent); half of uninsured boomers (50 percent) opposed the mandate.
As to be expected, physician awareness of the ACA is relatively high but, interestingly, not necessarily comprehensive. Physicians feel somewhat disengaged, and that the medical profession has been left out of the health care reform debate and the opportunity to engage in forming health policy (see figure 6).
Most physicians (71 percent) feel "somewhat" informed about the ACA but less than one-quarter of physicians consider themselves to be "very" informed (see figure 7). More female physicians feel knowledgeable to some degree about the health care reform legislation (83 percent women versus 65 percent men) but more of their male colleagues are likely to be "very" informed (29 percent men versus 11 percent women). Those who feel most knowledgeable about reform tend to be older (60+years) than their colleagues; surgical specialists feel more knowledgeable than other branches of medicine (see figure 7).
Figure 6: Physician perceptions of medical profession engagement in health care reform debate
Figure 7: Physician self-assessment of being informed about the ACA
Physician opinion is split as to the fate of the ACA, with 41 percent feeling that the act should be repealed altogether, and 49 percent disagreeing with this option. Physicians clearly believe that the ACA should be amended; only 26 percent favor leaving the act alone "to see what happens," and 66 percent disagree with this option. Two out of three physicians (more non-surgical specialists) support amendments to increase insurance access for the uninsured and to reduce costs; letting states develop alternatives to ACA mandates is supported by six out of 10 physicians.
Physicians clearly believe that the ACA should be amended; only 26 percent favor leaving the act alone "to see what happens," and 66 percent disagree with this option.
When employers were asked, "How well do you understand the health care reform law and its requirements for insurance coverage for employees?" 49 percent indicate that they have "some" or "limited" understanding and 2 percent say they don't understand it at all. By contrast, 6 percent feel that they have an "excellent" and 42 percent a "good" understanding of the law. The level of understanding is significantly higher among larger firms, with 25 percent of employers with 2,500 or more workers rating their understanding as "excellent." Executives responsible for health benefits programs are the most likely to report an "excellent" to "good" understanding, at 76 percent, higher than for other types of respondents, such as owners, CEOs, CFOs (50 percent) or CHROs (60 percent) (see figure 8).
Figure 8: Business executive understanding of the health care reform law and its requirements for health insurance coverage for employees
Employers appear to be very familiar with certain elements of the ACA, particularly provisions applicable to employee benefits. Familiarity is highest with the individual mandate, with 72 percent of employers reporting their familiarity to be an eight, nine, or 10 on a 10-point scale. High familiarity with coverage of essential benefits follows, at 53 percent, and then familiarity with the establishment of exchanges (45 percent) and the introduction of bundled or episode-based payments for hospitals and physicians (20 percent). The largest employers are considerably more familiar with these elements than are smaller employers. Again, executives responsible for health benefits programs are often the most familiar with each individual component, much more so than owners, CEOs, CFOs, or office managers.
In contrast to their overall understanding of and familiarity with the ACA, most employers report not being well prepared to implement or respond to its 2014 provisions. On a scale of one to 10, with 10 being fully prepared, just 28 percent of employers report a score of eight, nine, or 10. Smaller companies (those with 50–100 workers) are less likely to report being well prepared, at just 24 percent, versus 39 percent for larger companies with 2,500 or more workers.
In contrast to their overall understanding of and familiarity with the ACA, most employers report not being well prepared to implement or respond to its 2014 provisions.
What might be achieved by health care reform?
Consumers, physicians, and employers agree: Reducing health care costs will not result from the current reform effort.
Views of health care reform's likely success in achieving certain goals are muted. Around one-fourth of consumers feel that health care reform will successfully increase access to health insurance coverage, and around one-fifth believe that reform is likely to be successful in increasing the quality of care, motivating individuals to improve their health, better coordinating care, and ensuring access to the latest technologies. Only 16 percent feel that health reform will successfully decrease health care costs overall, with 32 percent believing the contrary (see figure 9).
Physicians are not particularly optimistic about health care reform achieving key objectives such as increased access to care and more efficient care. Almost three-fourths of physicians (73 percent) anticipate a shift in demand towards the emergency room if PCP visit slots are full due to ACA-related changes; they also expect longer ER "wait times" (68 percent). Half of physicians believe that there will be decreased access to health care due to hospital closures resulting from reform, and over half (53 percent) believe that reform is unlikely to encourage patients to live healthier lifestyles.
Figure 9: Consumer views on likely success of the health care reform law
Figure 10: Physician views on likely outcomes of health care reform
Over half (55 percent) feel that payment and efficiency reforms are likely to be implemented, believing that the system will shift physician incentives from volume- to performance-based payments; in addition, around six in 10 physicians believe that efficiency measures such as the implementation of evidence-based medicine (62 percent) will eventuate. Physicians feel that the ACA is unlikely to reduce health care costs by increasing the efficiency of doctors and hospitals (72 percent); unlikely to reduce costs of prescription drugs (63 percent); unlikely to achieve a better balance in the system between utilization of primary care and specialist care (58 percent); or to encourage consumers to adopt healthier lifestyles (53 percent) (see figure 10).
With respect to health insurance, most physicians believe that reform will increase access to government insurance programs but not reduce costs. Anticipated long-term impacts of reform on the system include fewer uninsured, increased wait times for primary care appointments, and decreased quality of care due to increased use of mid-level providers to manage access. Physicians expect that the ACA will lead to increased Medicaid and Medicare managed care programs (85 percent) and increased "wait times" (83 percent). The most unlikely outcomes due to health insurance reforms include reduced administrative paperwork required by insurance plans (73 percent) and reduced health insurance costs for consumers (68 percent). Nearly all physicians anticipate that in response to the ACA, insurance plans will seek higher premiums from employers (91 percent) and make lower payments to providers (90 percent), and nearly eight out of 10 physicians believe that the insurance industry will become more tightly regulated as a result of reform.
Each group envisions a different set of health care reform solutions. Employers and consumers respond favorably to improved coordination and incentives for performance; physicians prefer solutions that empower them to care for patients without outside intrusion.
Physicians are particularly concerned about the personal financial implications of the health care reform law; most physicians think their income will decrease or be flat as a result. Only 4 percent of all physicians surveyed believe that their income will increase next year; nearly half believe that their income will decrease. This is particularly the case for surgical specialists, who believe that their net income will decrease as a result of health care reform (64 percent versus 38 percent of PCPs and 46 percent of non-surgical specialists). This concern about deteriorating personal income appears to be at odds with physician views that the ACA will not reduce the overall costs of health care. Physicians are unhappy about payment system reforms, believing that the shift from fee-for-service to performance-based compensation exposes physicians to higher risk and lower income. Nine out of 10 physicians fear the new payment systems mean they will receive inadequate payments for new services or bundled payments, and they will have to pay higher administrative costs to implement and comply with the systems. Other key financial risks noted by physicians include being penalized for focusing efforts on aspects of quality that are not measured or rewarded; having insufficient capital to invest in new infrastructure; and having payment based on problematic measures of quality or cost and unreasonable performance standards. Surgical specialists are significantly more fearful of experiencing a reduction in revenues through fewer referrals or lower utilization of services compared to PCPs and non-surgical specialists (88 percent versus 66 percent and 63 percent, respectively).
Employers do not appear to be contemplating moving away from providing health care benefits in response to provisions in the ACA: Only 9 percent of survey respondents work in companies (representing 3 percent of the workforce) said that they anticipate dropping coverage sometime in the next one to three years, versus 81 percent of companies (representing 84 percent of the workforce) that said they would not drop coverage in the near term, and 10 percent of companies (representing 13 percent of the workforce) said they did not know. Factors other than the ACA also influence executives' views, with executives being about as likely to consider dropping coverage due to independent events such as high premium increases as they are in response to a variety of ACA-related scenarios, such as the availability of subsidies for lower-income individuals.
Employers show interest in moving towards different ways of providing and purchasing employee health benefits. When a scenario of a defined contribution option for products offered through an exchange was presented, interest was strong, especially among companies with fewer than 1,000 employees: 53 percent of employers representing 38 percent of the workforce say they would be very orsomewhat likely to use an exchange as a channel for a defined contribution program, versus 30 percent of employers with more than 1,000 employees.
The ACA introduces a range of systemic reforms intended to reshape the practice of medicine. Innovations such as changing service delivery models and new payment systems find positive support with consumers but are challenging to physicians, posing considerable re-alignment and implementation issues. Many physicians are not convinced about certain elements of reform, particularly those that require physicians to redefine their roles and rethink service delivery models.
Consumers are supportive of system-of-care changes, with slightly over half of consumers (52 percent) believing that integrated health care delivery systems have greater potential to reduce overall costs and spending, provide greater value to consumers (49 percent), and deliver better quality of care (46 percent) than does a system of independent practitioners and hospitals. Consumers are open to using different care providers, with 50 percent believing that a nurse practitioner or physician assistant can provide primary care that is comparable in quality to that provided by a doctor. Close to half (47 percent) of consumers say they are willing to seek care from a nurse practitioner or physician assistant, and 25 percent will consider visiting a retail clinic if a physician is not available. Current utilization of such services is low, with just 10 percent of consumers indicating that they currently use either a nurse practitioner or physician assistant as a primary care provider. In 2012, 13 percent of consumers say they visited a pharmacist in lieu of a doctor, and 14 percent used a retail clinic for non-emergency care for either themselves or a family member or both.
Not surprisingly, physicians are skeptical about the use of mid-level service providers, with two-thirds of physicians (65 percent) believing that decreased quality of care due to increased use of mid-level service providers to manage access is a likely result of health care reform; significantly, more surgical specialists (76 percent) believe this to be the case compared to non-surgical specialists or PCPs. However, physicians feel that the health care system is likely to move in this direction, with the majority (55 percent) of physicians believing that over the next decade, primary care services will be delivered by other medical professionals – both independently and as an adjunct to physician services.
Physicians are not overly familiar with the range of pilot programs that are testing delivery system reforms, with around half of them being "very" or "somewhat" familiar with bundled payments (57 percent), accountable care organizations (55 percent), medical homes (53 percent), comparative effectiveness (52 percent), and value-based purchasing (42 percent). Physician-perceived barriers to adopting ACA elements such as electronic health records (EHR) are primarily the cost (66 percent) and the burden of implementation (54 percent). Regulatory issues present great challenges to physicians, with only one in four considering themselves "on target" to meet meaningful use, while only 5 percent are ahead of plan. Of concern, 23 percent say they are unfamiliar with the requirements.
Employers show interest in system reforms including health insurance exchanges (HIX), with 45 percent of employers (representing 65 percent of the workforce) feeling highly familiar with HIXs. Many are interested in using exchanges – particularly if a large choice of plans is offered. Anticipated changes to companies' benefits strategies in the next three to five years include increasing cost sharing with employees for deductibles and co-payments (69 percent), increasing employee premium contributions (68 percent), and increasing use of programs to improve employee health status (62 percent). Close to eight in 10 employers (79 percent) have no plans to terminate the company-provided subsidy for full-time employees or for dependents (69 percent).
In an environment where consumers, physicians, and employers all view the current health care system as delivering less than exemplary performance and being overly complex, costly, difficult to understand, and navigate, there are mixed views on health care reform. Notably, there is a decline in optimism and an increasing uncertainty among consumers about the merits of reform, a split vote from physicians, and a definite negative viewpoint from employers. Even uninsured consumers, who stand to benefit from the law, show an increasing uncertainty.
This wide-ranging ambivalence about the ACA is not altogether surprising, given the law's complexity, the lengthy implementation period, the magnitude of changes, and the degree of polarization in the public debate. It appears as if no single group has been able to successfully explain and clarify the law and to engage the many participants in the health care system.
Notable is consumers' skepticism about the likelihood of reform happening in the short to near term; physicians' ambivalence about whether the ACA should be upheld or repealed; and physicians' negative views about the law's personal impact, both on clinical autonomy and income. Physicians are cognizant of barriers to implementing reform, especially financial and operational barriers, and many may not be well placed to meet the law's pending requirements. From an employer perspective, smaller companies are less knowledgeable and less enthusiastic about the reform law, whereas mid-sized to large companies perceive some advantages. Executives in very large companies are quite knowledgeable about but less favorable toward the law. Business executives closest to managing a company's benefits tend to see health care reform in a more positive light compared to their C-suite colleagues and are also the most critical of the health care system's current performance. Finally, the majority of companies feel unprepared to implement the ACA's provisions.
Views on the likely success of health care reform achieving certain goals are muted. For the most part, consumers, physicians, and employers expect to see improvements in the quality of care and in increased access to the health care system, although physicians have doubts as to whether the system can cope with the increased demand likely to occur with greater access. Consumers are open to new models of care, and employers are potentially interested in new models of insurance through health insurance exchanges. Physicians expect health reform to introduce quality improvements and a shift to performance-based payments. Physicians also expect overall quality to increase but are concerned about quality with respect to the emergence of other providers. In general, consumers, physicians, and employers concur that the ACA is less likely to be successful in addressing key ambitions such as effectively managing or decreasing costs, encouraging consumers to adopt healthier lifestyles, and reducing pharmaceutical costs. Many physicians remain unconvinced about numerous aspects of reform and anticipate an exit by physicians—either from health care or a shift into administrative roles.
All in all, two years after the ACA's enactment and in the lead-up to the key implementation years of 2013 and 2014, there are mixed opinions from the constituent groups of consumers, physicians, and employers as to the content and intent of health care reform.
All in all, two years after the ACA's enactment and in the lead-up to the key implementation years of 2013 and 2014, there are mixed opinions from the constituent groups of consumers, physicians, and employers as to the content and intent of health care reform. Differences are found among levels of engagement, awareness, and knowledge of the ACA and the extent to which essential pieces of the act are understood. Many look favorably on some, but not all, elements of the ACA. Consumers, in particular, are probably more remote from the law's specific content and the reform conversation in general; their growing uncertainty about the ACA may reflect their reliance upon what they read and hear in the broader public discourse. The overall expectation of consumers, physicians, and employers is that the ACA might achieve some goals in terms of improvements in quality and increasing access to the health care system, as well as introducing new service models such as integrated delivery systems and different insurance reforms such as health insurance exchanges. Opinion on the likely impact of the ACA on reducing health care costs is much less positive—one factor to foreshadow in the debate is whether it will be the ACA or increasing pressures on government budgets that will, ultimately, have the greatest impact on controlling or containing the growth of health care costs.
Closing thoughts
Federal, state, and local governments responsible for planning the future of the U.S. health care system should consider the following issues and questions:
- Is transforming the health care system to one that is consumer-driven a "big bet" or a "done deal"? There is significant opportunity to engage all stakeholders in the system more effectively. What must policy makers and industry stakeholders do to align interests toward engagement? Opportunities range from improving stakeholders' value proposition to bringing economic interests into line with what constituents value and seek from health care, to using communication channels to develop a better understanding of how best to engage consumers, physicians, employers, and others more meaningfully in decisions that affect their health and the care they consume, provide, or purchase.
- Physicians recognize that care and business models are changing rapidly; what strategies and steps will be necessary to achieve a stable delivery system that provides reasonable income security, administrative support, clinical autonomy, and a strong inter-disciplinary pipeline of health workers with a variety of educational and training backgrounds to deliver the new models?
- Evidence-based medicine is intellectually accepted as the "gold standard" by most physicians, but is a concern to physicians if applied incorrectly. Policy makers may consider a "tools, not rules" approach as evidence is applied to physicians' credentialing, performance reviews, and public reporting of outcomes and safety.
- How can increased transparency to facilitate system performance comparisons be achieved? For physicians, hospitals, health plans, drug manufacturers, and other industry sectors, regulatory and market demand for transparent demonstrations of service, cost, and quality are pre-eminent.
- How can government agencies with responsibility for implementing the ACA and health care system strategy better coordinate and target factors including population health issues such as diabetes, obesity, smoking cessation, and so on? Agencies might consider a crosswalk linking initiatives such as the ACA, FDA disclosures, state oversight of health plans, the National Practitioner Database, the Patient Quality Reporting Initiative, et al, to identify potential for joint courses of action.
- The national debate around health care reform and the quest for a sustainable system that provides higher-quality care at lower cost have highlighted the critical role of health information technology. Providers increasingly are being pressed to demonstrate value in terms of evidence-based care, improved outcomes, and reduced complications. This accountability is driving a greater reliance on data, necessitating that it be collected electronically, shared appropriately, and analyzed methodically. How can policy makers get the clinical practice sites "over the hump" of implementation barriers, particularly concerns about increased costs, operational disruptions, and a feared loss of autonomy?
- Abundant and rapidly growing health care information is available to consumers through online and social media sources. How best can this be leveraged to policy makers' advantage to educate, inform, and advise consumers to act accountably and to appropriately engage with the health care system?
EndnotesView all endnotes
- Congressional Budget Office. The Budget and Economic Outlook: Fiscal Years 2012 to 2022. January, 2012.
- Berwick et al. Health Affairs, May 2008 vol. 27 no. 3, 759-769.
- Centers for Medicare & Medicaid Services, NHE Tables 2010. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/tables.pdf. Accessed April, 2012.
- Davis. K., C. Schoen, and K. Sremikis. Mirror, Mirror On the Wall: How the Performance of the U.S. Health Care System Compares Internationally: 2010 Update. Washington, DC: The Commonwealth Fund, 2010. Wyss. D., N.G. Swann and M. Mrsnik. Global Aging 2010: In the U.S., Going Gray will Cost a Lot More Green. Standard & Poor's, October 25, 2010.
- Centers for Medicare & Medicaid Services, NHE Tables 2010. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/tables.pdf. Accessed April, 2012.
- Centers for Medicare & Medicaid Services. National Health Expenditure Projections 2010-2020 https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads//proj2010.pdf. Accessed April, 2012.
- Ibid.
- The Impact of Health Reform on Health Insurance Coverage: Projection Scenarios over 10 Years, Deloitte Center for Health Solutions. September 2011. www.deloitte.com/us/coveragemodel.
- Mrsnik. M., and I. Morozov. Mounting Medical Care Spending Could be Harmful to the G-20's Credit Health. Standard and Poor's, January 26, 2012.
- Ibid. p. 4.
- Swann. N et al. Global Aging 2011. In the U.S., Going Gray Will Likely Cost Even More Green, Now. Standard and Poor's , June 21, 2011
- Congressional Budget Office. The Budget and Economic Outlook: Fiscal Years 2012 to 2022. January, 2012. p.3.
- Ibid p. XIII.
- Ibid. p. 55.
- The Hidden Costs of U.S. Health Care, Deloitte Center for Health Solutions and Deloitte Center for Financial Solutions. March 2011. Analysis based upon projected 2009 data.
- Bureau of Labor Statistics, 2010. http://www.bls.gov/news.release/pdf/ecopro.pdf, http://www.bls.gov/opub/mlr/2012/01/art1full.pdf Accessed April, 2012.
- Bureau of Labor Statistics. The Employment Situation March 2012. www.bls.gov/news.release/pdf/empsit.pdf. Accessed April 2012.
- Dept. of Labor Bureau of Labor Statistics. Employment Projections. http://www.bls.gov/emp/ep_table_201.htm. Accessed April, 2012.
- Academy Health and Robert Wood Johnson Foundation. Changes in Health Care Financing and Organization (CHCFO). Public Perspectives on Health System Delivery Reforms. www.academyhealth.org/files/HCFO/HCFOBrief0609.pdf. Accessed April 2012. Blendon, R.J. et al. Americans' Views of Health Care Costs, Access, and Quality. The Milbank Quarterly, Vol. 84, No. 4, 2006 (pp. 623–657) Bernstein. J., Public Perspectives on Health Delivery System Reforms. Issue Brief. Academy Health and Robert Wood Johnson Foundation. 2009.
- 2012 Survey of Health Care Consumers in the United States, Deloitte Center for Health Solutions. June 2012.
- Physician Perspectives about Health Care Reform and the Future of the Medical Profession, Deloitte Center for Health Solutions. December 2011.
- Vanderbilt Center for Evidence-based Medicine. "Core Beliefs of HealthCare Consumers," December 2006.
- Murray. T.H. "American Values and Health Care Reform," NEJM, 362:4 January 28, 2010.
- Academy Health and Robert Wood Johnson Foundation. Changes in Health Care Financing and Organization (CHCFO). Public Perspectives on Health System Delivery Reforms. www.academyhealth.org/files/HCFO/HCFOBrief0609.pdf. Accessed April 2012.
- Oberlander. J. and J. White. "Public Attitudes Toward Health Care Spending Aren't The Problem; Prices Are," Health Affairs, 28, no.5 (2009):1285-1293.


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John Terzani
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John Terzani may have been suicidal but the former Mahopac resident also was exhausted, sick and shouldn't have been shot to death by state police during last week's standoff, his family has alleged.
"The police forced this standoff to come to an end and are at least partly to blame for killing an exhausted and distraught man who was pacing and vomiting for most of the time during this 'standoff,' " Terzani's sister, Beverly Rea of Hopewell Junction, said in a statement.
Terzani, 40, a 1991 Mahopac High School graduate, was killed Aug. 20 by state police after he reportedly pointed a loaded ...


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Marine Science Technician 1st Class Michael Shannon takes a sample near a Sewaren, N.J., oil tank that was damaged by Hurricane Sandy. MST1s and other Coasties may qualify for a new warrant officer program. (Coast Guard)
- Filed Under
Environmental response experts looking for leadership opportunities now have a chance to move up, thanks to a brand new warrant officer specialty.
The Coast Guard is looking for marine science technicians, boatswains mates and existing warrant officers with pollution response training to take positions in the marine safety specialist response specialty, which will begin board selections next year.
An Oct. 7 servicewide message, ALCOAST 434/13, outlined the new job, explaining that an MSSR chief warrant officer will fill in some of the gaps in the services marine environmental response capabilities, which have declined in the past decade.
The message cites the Cosco Busan and Deepwater Horizon oil spills, in addition to Hurricane Katrina, as examples where leadership expertise would have helped the service better respond.
During responses, a lot of times, theres not always an awareness at the leadership level of what an MER response is or how that capability works, program coordinator Lt. Renee McKinnon told Navy Times.
An in-house chief warrant officer can help close the expertise gap between enlisted specialists and officers, McKinnon said.
You usually have ensigns, [lieutenants junior grade], even lieutenants, that may or may not have done a tour within an incident management division or [marine environmental response], to have the ability to really gain that expertise as a leader.
The specialty is also a win for enlisted Coasties focusing on environmental response, she said. They now have a new leadership role to fill within their specialty.
They could do chief and senior chief, but there was no warrant officer specialty for them, so they didnt have a lot of ability to take that expertise and then use it as a leadership level, other than being a chief in the office, she said.
Members of the MSSR specialty can be stationed at sector or marine safety unit response incident management divisions, strike teams and the National Pollution Funds Center.
The Coast Guard will start with a board for the lateral transfer of Marine Safety Specialist Deck warrant officers next year, followed by enlisted boards at a later date.
Petty officers first class who are eligible for promotion to chief can apply for the program. They must:
■Hold an Operations Section Chief Type 3 qualification.
■Hold a Federal On-Scene Coordinator Representative or Response Supervisor qualification.
■Have served in a position within a pollution response unit during the past five years.
McKinnon said she couldnt specify the number of warrant officers and enlisted members already eligible for the new specialty, but she said most marine science technicians and many boatswains mates regularly complete FOSCR and RS qualifications.
Those selected will be eligible to move once theyve finished their tours or could take over if an existing MER billet at their duty station is converted to an MSSR billet.
There are 17 active-duty and 18 Reserve billets open, but McKinnon said that number will grow up to 50 total openings in the next few years and more than 80 as the program progresses.
What we see for this specific specialty is the ability for it to grow, she said. So our units will have the ability to look in-house and say, I think it would be great to have an MSSR here instead of maybe a chief or [lieutenant junior grade]. Thats something that each operational unit is going to have to decide.
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The recently announced Bari-Verona direct connection is a proof of how timely and market-sensitive Volotea is: in addition to Venice, Apulian travelers will easily take off
to the city of the Arena, starting from next December 20. Four weekly flights from Bari to Verona will be offered at really cheap prices, starting from 19 euro.
Verona will also serve as a connection airport from Northern Italy and Europe to reach Puglia, always an attractive destination for international travelers.
Volotea can offer much more to budget tourism than other air carriers: seat assignment is free and a brand new fleet of Boeing 717 aircrafts are specifically configured to accommodate less passengers than usual, so as to ensure maximum comfort.
Gino Lorenzelli
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Ali del Levante N.53 2012
PUGLIAIRBUS - Apulia sky and roads
Pugliairbus is the land transport service that connects the airports of Brindisi, Foggia, Taranto and Bari. Bari airport is also connect with the city of Matera world heritage and also UNESCO site.


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NORTH KINGSTOWNŌĆöSenior night.
For nearly every high school athlete, itŌĆÖs the one event that always leaves a lasting impression.
It was certainly a special night Tuesday for the eight seniors on the North Kingstown boys basketball team ŌĆō Jake Mansfield, Spencer Bode, Grant Gillis, Chris Lenox, Evan Gaudreau, Isaiah Butler, Kellen Coleman and Zac Brady. But for Brady in particular, it was a momentous occasion.
ŌĆ£Just to start in the varsity game made my high school career,ŌĆØ he said after the game. ŌĆ£If I scored thatŌĆÖs just a bonus. It was good that I scored, but I was more excited just to be a part of the starting lineup.
ŌĆ£ŌĆ"It just made me feel like an actual player out there. Even though IŌĆÖm a part of the team, it made me feel more like a teammate, rather than a manager.ŌĆØ
Looks can be deceiving.
DonŌĆÖt judge a book by its cover.
Pick whichever clich├® youŌĆÖd like for underestimating someone, and it likely applies to Brady. Upon first glance, itŌĆÖs easy to see why.
As his father Jim explains it, he and his wife Linda were at his brotherŌĆÖs wedding in Virginia when they noticed 15-month old Zac was not acting like himself.
ŌĆ£We brought him to the hospital, and they thought it was viral meningitis,ŌĆØ Jim Brady says. ŌĆ£He started to improve, and they sent him home.ŌĆØ
The next day ŌĆō back in Rhode Island ŌĆō Zac ŌĆ£crashed,ŌĆØ and was admitted to Hasbro ChildrenŌĆÖs Hospital in Providence where it was later discovered he had encephalitis.
ŌĆ£ItŌĆÖs the worst thing you could go through as a parent,ŌĆØ Jim Brady says.
Zac spent the next two weeks in intensive care at Hasbro, and the virus left him with ŌĆ£gross fine motor issues,ŌĆØ as his father put it.
Even with his physical limitations, Zac never let them define who he was and ultimately, they would become the impetus to his persevering personality.
Zac walks the way he walks.
Not different, just in his own way ŌĆō the only way he has ever known. And thatŌĆÖs how, as he grew up, he played sports.
It wasnŌĆÖt until around sixth grade though, he fell in love with basketball.
ŌĆ£Sixth grade was when I started to get involved with Special Olympics,ŌĆØ he says, ŌĆ£and I just loved basketball ever since.ŌĆØ
From there he spent many of warm summer days in the backyard perfecting his shot ŌĆō upwards of two-plus hours at a time ŌĆō and anyone who has seen him play before knows, heŌĆÖs lethal from beyond the arc.
It wasnŌĆÖt until two years later though, when he went to an open tryout for the Davisville Middle School basketball team in eighth grade that Zac truly understood what the sport meant to him.
ŌĆ£I went to the first open gym,ŌĆØ Zac says, ŌĆ£and I never went to the second open gym.ŌĆØ
While he did not make the team as a player, DavisvilleŌĆÖs coach at the time, Kyle Bodington, saw something in Zac that could be a major asset to his team.
ŌĆ£He was real disappointed, but I knew I could get him to be a big part of the team,ŌĆØ Bodington says. ŌĆ£I think he was upset not making [the team with] the initial group of guys.ŌĆØ
So Bodington ŌĆō who called Brady ŌĆ£one of his favorite kids heŌĆÖs ever coachedŌĆØ ŌĆō enlisted one of his ZacŌĆÖs friends, Alex Gershkoff, to ask Zac to come back to the team as the manager. It would prove to be a defining moment in his young life.
ŌĆ£It made me understand who I am,ŌĆØ Brady says. ŌĆ£Obviously I canŌĆÖt be out there, but itŌĆÖs just fun being around the team. Even though I donŌĆÖt play, itŌĆÖs still a good experience because I want to be a coach when IŌĆÖm older.
ŌĆ£At first I was mad that I wasnŌĆÖt out there, but now because of Special Olympics and Unified IŌĆÖve got my own season. ItŌĆÖs just fun hanging out with these guys.ŌĆØ
Zac may not have been on the court all the time ŌĆō he did get into a few games at Davisville ŌĆō but he was undoubtedly a big part of the team.
Zac talks the way he talks.
Not different, just in his own way ŌĆō the only way he has ever known. And thatŌĆÖs how, as he grew up, he learned about basketball.
Uneducated people often associate stuttering with lack of intelligence, but more often than not that stereotype couldnŌĆÖt be any further from the truth. Zac Brady is a perfect example of that, and anyone who knows him can attest. HeŌĆÖs articulate, intelligent and well spoken.
ŌĆ£IŌĆÖve sat next to him in classes and heŌĆÖs helped me more than I could have ever have thought of it,ŌĆØ Bode says. ŌĆ£WeŌĆÖre in the same advisory, IŌĆÖve had class with him every single day since freshman year. IŌĆÖve changed schools, my sophomore year I didnŌĆÖt go [to NK] and when I came back he was still my friend.ŌĆØ
Being the well-spoken individual he is, when Zac got to high school he expressed to head boys basketball coach Aaron Thomas that he wanted to be the team manager ŌĆō insisting on being with the varsity according to both his father and Thomas.
ŌĆ£From day one heŌĆÖs been a part of the team,ŌĆØ Thomas says. ŌĆ£I mentioned to the players sometime when he was a freshman, I said guys, ŌĆśif thereŌĆÖs any issues with Zac anywhere, I expect to see you guys stand up for him.ŌĆÖ The players reassured me of that. They have.ŌĆØ
A big part of that was Derryck Kilgore, a senior on the team who was in attendance Tuesday night to watch Zac get his first career start.
ŌĆ£[Thomas] just told me that we had a new manager,ŌĆØ Kilgore says. ŌĆ£As soon as I found out I just wanted to get to know the kid. HeŌĆÖs actually a really good kid. My senior year wouldnŌĆÖt have been as fun as it would have been if not for Zac.
ŌĆ£ŌĆ"Even off the court, I was always seeing Zac in classes, always running into him, always messing around with him in the hallways. Having fun. It feels like just yesterday I came onto the court for my senior year and he was a freshman.ŌĆØ
Since his freshmen year some of the teammates have changed, but itŌĆÖs always been the same Zac; heŌĆÖs a part of the team.
ŌĆ£We see him as one of us,ŌĆØ senior Jake Mansfield says. ŌĆ£When we go around talking to each other, we talk to him as one of us.ŌĆØ
Whether it was joking with Kilgore or shooting contests with Owen Heath, Zac has always been a Skipper. ThatŌĆÖs what made Tuesday night so special, not just for Zac ŌĆō who by far received the loudest ovations of the night ŌĆō but for his teammates too.
Brady scored the first points of the game against Coventry ŌĆō on an uncharacteristic 1-for-3 performance from the senior sharpshooter ŌĆō before making his way back to the bench, where he sat with his signature smile.
In the end, it couldnŌĆÖt have gone any better for NK. All of the seniors got to play, they won the game and the division, and Zac even got a few more seconds at the end of the game.
ŌĆ£It was fair,ŌĆØ Thomas says. ŌĆ£Some years I would say that kids would say, ŌĆśoh, come on,ŌĆÖ but not this year. Every kid went, ŌĆśabsolutely, what do you want us to do coach.ŌĆÖ
ŌĆ£ŌĆ"The point we made to the kids was some things are more important than winning and losing. HeŌĆÖs getting on the floor. HeŌĆÖs earned the right to be on the floor, so whatever happens, happens. HeŌĆÖs been a great manager, a great scout for us, heŌĆÖs helped us out tremendously. ItŌĆÖs his time.ŌĆØ
Zac is who he is.
Not different, just in his own way ŌĆō the only way he has ever known. And thatŌĆÖs how, when grows up, heŌĆÖs going to be involved in basketball.
Tuesday night was undoubtedly a special one for Zac Brady, seeing his first varsity action and getting his first varsity points. But, it is what he has done off the court that is going to truly prepare him for life.
In addition to his managerial duties, Zac has also gone out and scouted other high school teams. According to Thomas and the players, his reports are spot on. It is part of what has led him to continue his involvement with basketball at Johnson & Wales in the fall, where he intends to major in sports management ŌĆō with the ultimate goal of getting into coaching.
ŌĆ£Sports management isnŌĆÖt about coaching; itŌĆÖs about events, all those big raffles at games but at Johnson & Wales they have a minor in coaching,ŌĆØ he explains. ŌĆ£ThatŌĆÖs what attracted me, and Johnson & Wales isnŌĆÖt that far away. I figured it would be a nice school to go to.
ŌĆ£I e-mailed the [basketball] coach, and IŌĆÖm trying to be the manager of the basketball team at Johnson & Wales. If everything works out, IŌĆÖll be able to do what IŌĆÖm doing now over there.ŌĆØ
ThereŌĆÖs little doubt that Zac Brady will succeed in whatever he puts his mind to. In his life, heŌĆÖs fallen down ŌĆō ŌĆ£a lot,ŌĆØ he says with a smile ŌĆō but that is not what has defined him; itŌĆÖs his ability to pick himself up each time he does.
ŌĆ£ItŌĆÖs not how many times you fail, itŌĆÖs about how many times you learn from it,ŌĆØ he says. ŌĆ£If you love something, you shouldnŌĆÖt give up even though itŌĆÖs tough. IŌĆÖve always been that way.ŌĆØ
And likely always will.


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Banana cream pie comes in both vegan and non-vegan versions at Revolution Kitchen. / GLENN RUSSELL/FREE PRESS
Julia Loewer, 14, remembers a recent dinner with her family at a well-known Stowe restaurant. Almost everything on the menu contained meat. What was a vegetarian to do?
I ordered the corn chowder and it had bacon bits in it, the Waterbury teenager recalled. I basically tried to eat around them and pull them out, but it was nerve-racking because I didnt want to eat any of them.
Welcome to the world of Vermonts vegetarian and vegan diners. They live in an era that celebrates bacon, pork belly, ribeye steaks and duck confit. For vegetarians, dining out can mean scouring online menus, calling ahead, interrogating waiters and searching for the quality and diversity of choices easily available to meat eaters.
The opening in August of Revolution Kitchen, a vegetarian fine-dining restaurant in Burlington, threw into relief the near-absence of similar restaurants in Vermont.
Yes, the state has its share of no-meat-served bakeries, tea houses and juice bars. Yes, Waitsfields Mint restaurant offers vegetarian fare in the Mad River Valley, and Superfresh Organic Café in Brattleboro will begin serving a dinner menu this winter in far southeastern Vermont.
And, yes, a growing number of meat-serving restaurants also provide creative meatless fare that wins raves from vegetarians.
Nevertheless, some vegetarians say they are surprised at the relatively restricted choices in a state known for its embrace of 21st-century vegetable farms, environmentalism and left-leaning politics.
We were amazed when we moved to Vermont, at the lack of places to support vegheads, said Vicky Mills, 43, of Randolph, a grocery store manager who eats a vegan diet, one that excludes not just meat but all animal products.
Thinking wed be moving to a state that had a bigger support network than Georgia, we were excited at first. But, weve had countless why would you not eat dairy and live in Vermont? type comments, she added.
Question of scale
On the other hand, perhaps the lack of purely vegetarian restaurants is not so surprising. A 2008 survey commissioned by Vegetarian Times magazine found that only 3 percent of American adults described themselves as vegetarians, although 10 percent said they follow a vegetarian-inclined diet . Less than 1 percent self-identified as vegan.
Even if the number of vegetarians in Vermont runs higher than the national average, non-meat-eaters represent a relatively small slice of the restaurant dining public.
At a destination like Stowe Mountain Resort, the sheer number of customers as many as 10,000 meals a week, said Executive Chef Josh Berry means he can offer a separate menu for vegetarian and vegans.
But smaller restaurants with smaller staffs and shorter menus often are able to offer little choice. That leaves vegetarian diners either discouraged (For the most part, I dont eat out, said Danny Weiss, 61, of Burlington) or in search of those eateries that go out of their way to be vegetarian-friendly.
Vermonts pretty cutting edge, its one of the more embracing states, said Michael Yaeger, 41, of Berlin, who describes his wife and himself as a pretty devout restaurant-goers.
Yaeger is one who sees Vermonts glass as half-full rather than half-empty. On a recent trip to the Finger Lakes the couple found some restaurants lacked any vegetarian option, he said, while in Vermont because we have fewer chain restaurants and maybe because of the farm-to-table movement, most restaurants offer at least one entrée.
Is one vegetarian dish enough? Its better than nothing, he said. But it sucks if we both have to order the same thing I love Revolution Kitchen, but its more important to us that normal restaurants offer vegetarian choices.
My pet peeve is when a restaurant has that one obligatory vegetarian pasta dish, happens all the time, Leila LaRosa, 39, of Chelsea, echoed in an email. Other vegetarians chimed in, venting about restaurants that serve token options frozen veggie burgers were mentioned or rarely change their vegetarian offerings.
So where do vegetarians enjoy eating in northern Vermont? Several diners named Montpeliers vegetable-friendly Kismet and some more unexpected choices, including the Cider House, a Waterbury barbecue place, and Burlingtons Farmhouse Tap and Grill, best known for its burgers.
A number of ethnic restaurants particularly A Single Pebble in Burlington came in for praise.
You go to Single Pebble, they are used to vegans so it is easy and comfortable, said Mills, the Randolph vegan. She started to talk about pizza places, then interrupted herself. You do have to quiz the waiter. At one place, the pizza seemed to be vegan, but it turned out there was Parmesan in the sauce.
Some chefs enjoy the opportunity to cook in a way that may be new for them. She and her husband call ahead when they want to dine at Black Krim, a tavern in their small town, and They say, oh cool, fun. They are excited by the challenge, Mills said.
Yaeger said he has purchased a domain name, vegetarianvermont.com, and hopes soon to launch a website that will explore vegetarian dining in the state, with restaurant reviews.
Chefs and restaurant owners said they recognize not just the number of vegetarians among their customers, but the growing number of people who eat a gluten-free or dairy-free diet.
Were trying to provide a wider variety of choices, said David Hoene, chef-owner of Paulines in South Burlington. Im always thinking about the vegetarian who comes in regularly. We need to treat them with the same respect as any other customer.
We have to be prepared for everything, said Berry, the Stowe resort chef. Were a resort. People come in their pjs to breakfast we have to have gluten-free pancakes available. ... Vegetarians are so happy to have their own menu.
The kitchen has created a number of vegetarian and vegan dishes off the beaten path. One of the most popular is nanbanzuke, a Japanese tempurad dish usually made with fish. Berrys version begins with Vermont tofu dusted with rice flour and flash-fried, then combined with vegetables, charred lemon and a sauce based on soy caramel and rice vinegar.
The dish is popular with non-vegetarians as well, he said. Other chefs made similar comments, saying it is difficult to estimate how many of their customers are vegetarians since creative, well-presented vegetable dishes appeal to meat-eaters, too.
Bill Scully owns Pangaea, a Bennington restaurant with 25 items on its tavern menu; 14 of the 25 are vegetarian or can be prepared without meat.
Vegetarians want the same thing as meat-eaters, he said. A menu where everything tastes good.


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I have made a draft remote application on the top of libpq for PostrgreSQL. It behaves well, but I have profiled the general functionning of the application. For each final business result that I produce, it happens that I call something like 40 select clause (over tcpip).
I have reminiscences from SQL-Server reminding me to minimize the number of interactions between my remote application and the database. Having analyzed my selects, I do think I could reduce this number to 3 select clause, using jointures. But I don't remember the syntax for using the result of a select in another select.
e.g. :
SELECT * FROM individual
INNER JOIN publisher
ON individual.individual_id = publisher.individual_id
WHERE individual.individual_id = 'here I would like to use the results of a another select'
this other select would be simply of the kind:
SELECT identifier FROM another_table WHERE something='something'
How would you write that ? What is the name for describing the action of redirecting one select into another , if any name ?
EDIT: in the answer given i've been ask to give the tables layout. Here it is simplified, declined a number of times for different item_types... ( 3 totally different types, hence the 3 sql queries if optimized).
table passage
PK: id_passage
text business_field_passage
table item
PK: id_item
FK: id_passage
text business_field_item
table item_detail
PK: id_item_detail
FK: id_item
text business_field_item_detail
bytea image_content
there are several id_item for one id_passage. there are several id_item_detail for one id_item.


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Man, you know that feeling when you finaly meet the one person who you've always looked up to? That person, who you have always thought is perfect in every way, shape and form? And you know what always happens when you get to say hi? You're let down. That's how I feel right now.
I, of course, have not gotten to meet Lebron face to face, and it is more than likely that I never will. However, like most of the world, I have followed the Lebron saga all summer, and, through the camera lens, have met the real Lebron.
I totally repect Lebron's right to change cities, I even encouraged it from the start. Cleveland did not have the pieces to be a legitimate championship contender and didn't really have the capabilities to get them. Furthermore, the city doesn't have the swagger that is necessary to satisfy legends. Lebron needed to leave, and I'm glad he did.
But the way he did it?
Lebron's first mistake was not telling Cleveland from the start that he wasn't coming back. If Lebron had outright, from the beginning said he would not be returning to Cleveland, he still would have been the center of attention and gotten all the suspense he desired with where he was going. Deciding between Miami, New York and Chicago would have been good enough, he didn't need to lead Cleveland on like that as well. He lost so much respect from everyone for that.
Another mistake was the way he decided. An hour long tv special? Ok, that's fine, if you do it right. But doing it from a high school in Grenwich is not the right way to do it. It should have been a celebration, he should have informed the tam before hand, so they could set up the party the night of, not two nights after, like it happened. Sure, he gave some money to charity, but its not like that saved the hit his image took at all. If anything, it made him look worse, cause everyone recognized it for what it was, a pathetic attempt to save face, ingenuine, fake.
Finally, I have a serious problem with the decision he made. Miami??? I get that you want to play with your friends, but this was about something bigger. This was about legacies, untold riches and the fate of the NBA. Not some buddy-buddy bull shit. Lebron was in charge of saving the NBA by creating parody and competition. By reviving storied franchises, either the Bulls or Knicks. Instead, he took the easy way out.
So, in my book, Lebron went from the greatest athlete ever, with more spirit and expectations than anyone to a pathetic sidekick, to scared of his destiny to follow up. Even if he wins 7 titles in a row, Lebron is not ever going to be recognized with Jordan, Russel, and Magic, simply because of this debacle. Like I said, talk about disappointment.


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EATONTOWN — As the world gets on with its business in the coming weeks, the victims of superstorm Sandy wont be forgotten, but the focus will certainly fade.
And for those without a voice, the danger of being disregarded increases dramatically.
Indulge me for a moment while I share a few storm stories with you.
Like the one about the Englishtown veterinarian with a cat that was badly injured when a tree limb fell on her, but had no electricity.
Unable to operate, he got in touch with the Monmouth County SPCA, which brought the small gray creature to their generator-powered facility and performed surgery to fix a broken palate, stabilize a shattered rear leg and basically save her life.
Late last week, Twiggy, as theyve named her, was about as happy as any cat Ive ever seen as they pulled her from the cage, even though her leg was going to require amputation, which happened this week.
I love that one.
Or the boxer that local law enforcement grabbed in Keansburg after the owners evacuated and left the dog behind. As the water rose, the dog was still there, just trying to get back into its home.
I hope it gets a better home this time around.
There was a 91-year-old man who was prepared to die in his cold, dark apartment in Red Bank rather than be separated from his 10-year-old rescue dog, Terry.
When an SPCA worker who had regularly checked on the man over the years to make sure he had enough food and medicine for his companion went over a few days after the storm, the man was sick and the situation dire.
But it wasnt until he knew Terry would be taken care of until he could return home that he agreed to be transported to Riverview Medical Center, where he remains.
Terrys doing great.
There are legions of nameless heroes at shelters across the region. So let me put a name and a face on one of them.
Tina Thorp lost her job as a wholesale food buyer a year and a half ago and started volunteering at the SPCA in July, having adopted a dog last year. The Cliffwood Beach residents been part of their field team in the storms aftermath.
A couple of days after Sandy, when we were actually able to get on the roads, were driving down there was a woman who chased us down, she recalled. She couldnt take care of her dog. She lost her house of 42 years, everything she had in it, and come to find out had breast cancer and it just came back. She was living in her car but she finally found somewhere to stay, but they had four dogs so she had to keep her dog in the car. Now one of our volunteers is fostering her dog.
Everyones worried about their animals. There were people coming up to us crying because they couldnt find their animals. One of the first houses we stopped at we saw a Rottweiler in the yard. One of our volunteers got out to talk to her and she just broke down crying. She said, I didnt know what I was going to do. I have one can of dog food left.
Shes been dropping off food and blankets to desperate pet owners in Northern Monmouth County ever since.
Heres the kicker.
Thorps a Union Beach native. There are days she finds herself on the streets of her hometown, working among the destroyed homes of lifelong friends.
So lets cut to the chase here.
The human suffering over the past few weeks has been incredible. And the animals who enhance our lives so much havent fared so well, either.
Theres been a storm-related influx of animals turning up at shelters, in addition to the ones already there. And there just arent as many people coming in looking to adopt them right now.
So as life returns to normal, whenever that is, volunteer, donate and most of all, try to find a place in your heart and your home for one of these amazing companions.
Stephen Edelson: email@example.com; @SteveEdelsonAPP.


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Bluetooth® [1] is an available option that allows for wireless connections between your Toyota and many Bluetooth [1]-enabled mobile phones. Available on select Toyota models equipped with and without the available onboard navigation system, the technology provides users with convenient hands-free phone capabilities.
View demo on how to program your phone using your vehicle's Bluetooth [1] technology:
With DVD navigation system.
Without DVD navigation system.
Some Toyota vehicles now feature Bluetooth audio streaming capability, allowing you to stream mobile phone music through your Toyota vehicle. Find out if your phone is compatible here. [2]
For general information on Bluetooth [1] wireless technology, visit bluetooth.com
Want to know which phones are compatible with Bluetooth technology in Toyota vehicles? Visit toyota.com/connect
View demo on how to program your phone using your vehicle's Bluetooth [1] technology:With DVD navigation system Without DVD navigation system
Bluetooth FAQs
1. What is Bluetooth technology?
Bluetooth is a new wireless technology that enables connectivity between two or more devices (for example, cell phone and vehicle) by utilizing a 2.4-GHz radio spectrum that has a range of 10 meters. Bluetooth allows customers to use their compatible cell phones hands-free in the vehicle.
Due to variations among service providers, handsets and technology, keep in mind that not all Bluetooth handsets will offer the same level of functionality within Bluetooth-equipped Toyota vehicles.
2. How does Bluetooth work? (From bluetooth.com)
Bluetooth wireless technology is a short-range communications technology intended to replace the cables connecting portable and/or fixed devices while maintaining high levels of security. The key features of Bluetooth technology are robustness, low power and low cost. The Bluetooth specification defines a uniform structure for a wide range of devices to connect and communicate with each other.
Bluetooth technology has achieved global acceptance such that any Bluetooth-enabled device, almost anywhere in the world, can connect to other Bluetooth-enabled devices in proximity. Bluetooth-enabled electronic devices connect and communicate wirelessly through short-range, ad hoc networks known as piconets. Each device can simultaneously communicate with up to seven other devices within a single piconet. Each device can also belong to several piconets simultaneously. Piconets are established dynamically and automatically as Bluetooth-enabled devices enter and leave radio proximity.
A fundamental Bluetooth wireless technology strength is the ability to simultaneously handle both data and voice transmissions. This enables users to enjoy a variety of innovative solutions such as a hands-free headset for voice calls, printing and fax capabilities, and synchronizing PDA, laptop and mobile phone applications, to name a few.
More general information on Bluetooth can be found at www.bluetooth.com
3. What is the range of Bluetooth?
The vehicle Bluetooth system can pick up the Bluetooth signal from the handset up to 30 feet from the vehicle. The range is largely dependent on which phone is being used and the battery level of the phone.
4. Can any Bluetooth handset be integrated to the Toyota DVD navigation or audio system?
Because Bluetooth has a universal standard developed by a consortium of interested companies, almost all Bluetooth handsets should have some functionality in our vehicles. However, because of the differences in the quality of the handsets and Bluetooth chip programming, you may encounter different levels of functionality from one phone to another.
5. Is a charging cradle available for Bluetooth phones?
There is currently no charging cradle available from Toyota for Bluetooth handsets.
6. Which Toyota vehicles have Bluetooth technology?
Please visit toyota.com/connect for a list of Toyota vehicles that have available Bluetooth technology.
7. Is there any truth to the Internet virus rumor regarding the Toyota DVD navigation system and Bluetooth wireless interface?
A rumor has surfaced on the Internet indicating that a cell phone virus could be transmitted to the DVD navigation system in certain Toyota models through the Bluetooth wireless interface. Toyota Motor Sales, U.S.A., Inc., and its parent company, Toyota Motor Corporation in Japan, have investigated this rumor and have determined it to be without foundation for the following reasons: 1) Navigation and audio systems in Toyota vehicles do utilize an embedded operating system (OS) and some degree of random access memory (RAM) that are used to store several types of information such as recent destinations, names and attributes of saved destinations, and a telephone directory, among other items. The operating system itself is proprietary, however, not Symbian as these reports have alleged; and 2) Although the Bluetooth interface does support the Object Push Protocol for transferring the phone book from a Bluetooth cell phone to the DVD navigation system, this is an operator-controlled event and the data cannot be exported (or transmitted) from the navigation unit. Toyota Motor Sales, U.S.A., Inc., has responded promptly to all media inquiries regarding this matter. Contrary to the original story that appeared on ZDNET, Toyota was never contacted for comment by the writer.
BLU Logic®
8. What is BLU Logic?
BLU Logic is an accessory device that integrates with the factory audio system to allow convenient hands-free mobile phone use. With BLU Logic, users can answer incoming calls, hear calls through the vehicle's audio system and communicate through the fixed microphone provided. BLU Logic offers the ability to pair with up to seven different phones, automatic audio routing through the vehicle's front speakers, automatic muting of the vehicle's audio system when receiving or making a call, voice dialing for enabled phones and last number redial. Additionally, if the paired phone offers Advanced Audio Distribution Profile (A2DP) compatibility, users may even listen to music streamed from the phone through the vehicle's front speakers.
9. Which vehicles are compatible with BLU Logic?
BLU Logic is compatible with most new and late-model (2008+) Toyota vehicles without JBL® audio systems. BLU Logic may also not be compatible with some navigation-equipped vehicles. For specific vehicle compatibility information, please see your local Toyota dealer.
10. How do I get the best voice quality when using BLU Logic?
Because the BLU Logic system incorporates a technology to suppress background noise, users should speak in a normal conversational volume.
11. Where can I get more information about BLU Logic?
Please visit http://www.blulogicupdate.com for additional information or visit your local Toyota dealer.
12. What hands-free features are enabled through Bluetooth wireless technology?
Bluetooth technology is available on select DVD navigation system-equipped vehicles. This allows for hands-free cell phone use with certain handsets. Once the handset is paired to the vehicle (up to four different phones can be paired with one vehicle) and the handset information has been transferred (phone book and speed-dial numbers) into the DVD navigation system, the customer typically can enjoy the following hands-free benefits:
- Hands-free mobile phone operation with a built-in microphone and utilization of the audio speakers.
- Answering incoming calls with one touch of the steering-wheel control or the navigation screen.
- Automatic audio mute when receiving or making a call.
- Dialing a number by using the touch pad on the navigation screen.
- One-touch dialing on the navigation screen for speed-dial numbers (17).
- Making a call from the phone book (1000 numbers).
- Making a return call from the outgoing call log or the incoming call log (five most recent calls).
- One-touch dial to points of interest on the navigation screen.
13. How do I continue a Bluetooth call after I leave the vehicle?
The instructions for this procedure are included in the Installation Quick Reference Guide for each Bluetooth handset. Please select the instructions that correspond to your Bluetooth phone.
14. How many phones can be paired to the Toyota Bluetooth system?
Navigation-based systems can pair with four to six mobile phones depending on the vehicle. Bluetooth-enabled audio-based systems can pair with six cell phones.
15. If the systems can pair with multiple phones (four with navigation, six with audio), how will the systems determine which paired phones will be activated?
A system will search for the most recently used phone. If this phone is not in the vehicle (or turned on), the Bluetooth system will not be active. To activate Bluetooth a new phone can be paired, or an already paired phone can be selected for the Bluetooth system memory.
16. Can I transfer numbers from my Bluetooth phone to the vehicle?
Some phone and service-provider combinations allow you to download your phone book directly into the Toyota Bluetooth system. Others are more restrictive.
17. How can I activate my Bluetooth handset in my vehicle?
Different phone and service-provider combinations follow different protocols for pairing a Bluetooth phone to a hands-free device. Please refer to your phone's owner's manual for pairing instructions.
18. Which handsets can I utilize?
Bluetooth handsets can vary in quality and contain different Bluetooth chip programming. Therefore, not all Bluetooth handsets will operate at the same level. In order to account for this, Toyota is evaluating Bluetooth handsets and will identify those that work best with our system.
19. Can a customer buy any Bluetooth handset retail and have it work with/transfer to our system?
Because Bluetooth has a universal standard developed by a consortium of interested companies, almost all Bluetooth handsets should have some functionality in our vehicles. However, because of the differences in the quality of the handsets and Bluetooth chip programming, not all Bluetooth handsets will have the same level of performance when interfacing with the Bluetooth chips in our vehicles. That is why Toyota is evaluating Bluetooth handsets to help ensure quality operation.
20. Where can I find instructions on pairing the handset to the DVD navigation system?
These instructions are located at toyota.com/connect
21. What is the warranty on Bluetooth handsets?
Handsets are sold separately and typically have a one-year warranty through the manufacturer. Consumers should check with the handset manufacturer for details about the warranty.
22. Where is the best place to find information about Bluetooth in my Toyota?
Please consult toyota.com/connect for details on how a specific phone should perform with your Toyota Bluetooth system. Details on how to manage and pair most phones are provided.
23. Is there a phone number I can call instead of utilizing the Web site?
Yes, the phone number is listed on the Web site: 1-866-825-5460.
24. What does Wireless Local Number Portability (WLNP) mean?
This is a new government-mandated process that requires all wireless service providers to allow customers to maintain their current wireless phone numbers when they change service providers.
25. How does a customer take advantage of WLNP?
Customers and dealers should be aware of the following when trying to keep an existing phone number:
- Know the details. Your new carrier will need to know information about your existing account. So for convenience, bring a bill from your existing carrier to your new one. If you don't have a copy of your bill, know the exact details of your account, including name (for example, is it billed to "Bill" or "William" Smith), address, account number and phone number.
- Leave some time. The process can take a few minutes or a few hours. It could take even longer for your phone to be fully functional (such as being able to receive incoming calls).
- Timing counts. Start the process with your new carrier. If you cancel your current service with your existing carrier, you may end up losing your number.
- Are you a free agent? You may be under contract with your existing carrier, who may charge you an early-termination fee if you cancel your existing service while still under contract.
- Start from scratch. You may need a new phone when you switch carriers, even if you are keeping your number. Familiarize yourself with your new carrier's rate plans, coverage area and features, too, because you'll need to choose a new plan.
- Your consent is needed. Your new wireless carrier will need your authorization to move your wireless number from your old carrier. This protects you from carriers switching your number without your permission.
26. Will my wireless local number work if I move across the country?
The "L" in WLNP, "Local" means that when you switch carriers you will be able to keep your number within the same metro area, but you may not be able to keep it if you move outside that metro area.


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Help & Support
Contact us
Use the form below to send us your message – we'll be in touch as quickly as we can! If you prefer to get in touch by phone, refer to the table to the right.
Our friendly customer service agents are just one call away from helping you with any questions you have – whether they're about product coverage, billing or how to file a claim.
- Protection Plans855-792-2355
- Travel, Flight & Rental Car855-792-8747
- Renters Insurance
- Sales866-918-0331
- Claims800-358-0600
- Support800-432-8612


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The next meeting for the Gold Wing Road Riders Association Chapter K will be May 14 at Hooligan's in Plainfield. The meeting will start at 6 p.m., but come at 5 p.m. to join us for dinner and to socialize.
As GWRRA has grown, the "FUN" has increased tremendously. All around the world, members meet to ride, socialize and have fun. As diverse as the membership is, so are the fun activities. One such activity is our Dust Off Weekend. Dust off your bike that has been sitting all winter and join us for this fun-filled weekend. Whether you ride on two or three wheels, this is a perfect chance to see what being a member of GWRRA is all about.
Dust Off is May 17 to 19 at the Silver Springs Campground in Rio. There will be camping, cabins or hotels available. Friday and Saturday there will be a DJ, and we will enjoy sitting around the campfire. Friday night is a fish fry, and Saturday is an ethanol plant tour and various rides. Come join us for the entire weekend or just part of it.
Other activities this month are the Medford smelt feed on Friday, a tire-kicking on Saturday in Janesville, a mall show Saturday in La Crosse and a Minnesota bluff ride on May 25 and 26.
For more information about Chapter K and GWRRA, call Dave or Cheryl Freeman, membership coordinators, at 715-213-3533 or Don or Cheri Walloch, Chapter K directors, at 715-459-2449.