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Center for Studying Health System Change
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Key Findings from HSC's 2010 Site Visits
Health Care Markets Weather Economic Downturn, Brace for Health Reform
Issue Brief No. 135
Lingering falloutloss of jobs and employer coveragefrom the great recession slowed demand for health care services but did little to slow aggressive competition by dominant hospital systems for well-insured patients, according to key findings from the Center for Studying Health System Changes (HSC) 2010 site visits to 12 nationally representative metropolitan communities. Hospitals with significant market clout continued to command high payment rate increases from private insurers, and tighter hospital-physician alignment heightened concerns about growing provider market power. High and rising premiums led to increasing employer adoption of consumer-driven health plans and continued increases in patient cost sharing, but the broader movement to educate and engage consumers in care decisions did not keep pace. State and local budget deficits led to some funding cuts for safety net providers, but an influx of federal stimulus funds increased support to community health centers and shored up Medicaid programs, allowing many people who lost private insurance because of job losses to remain covered. Hospitals, physicians and insurers generally viewed health reform coverage expansions favorably, but all worried about protecting revenues as reform requirements phase in.
Dominant Hospitals Maintain Clout, Strong Bottom Lines
he economic downturns severity varied across the 12 communities, with 2009 unemployment rates ranging from 6.2 percent in Little Rock, Ark., to 11.1 percent in Greenville, S.C., compared with an average of 9.2 percent across metropolitan areas. Overall, large hospitals and hospital systems in the 12 communities weathered the recession fairly well, maintaining strong bottom lines, even in markets such as Cleveland and Miami, where the recessions impact was particularly severe (see Data Source). Most hospitals did see revenues decline and uncompensated care costs increase as privately insured patients struggled to pay out-of-pocket costs, shifted to Medicaid and other coverage for lower-income people, or lost coverage altogether. Reduced patient demand, particularly for elective procedures, decreased operating revenues, although hospitals noted that volumes already were stabilizing as local economies began to recover.
Most hospitals avoided operating losses during the downturn, however, in part by reducing staff, adjusting salaries and benefits, and improving productivity. Some hospitals postponed, scaled back or even canceled construction projects. Must-have hospitalslarge hospital systems and individual hospitals that health plans must include in their provider networks to remain attractive to consumerstypically maintained or increased negotiating leverage over private insurers. For these hospitals, commercial payment rates continued to increase faster than unit costs, offsetting losses on Medicaid patients and sometimes Medicare patients. Some independent hospitals and smaller systemsparticularly those serving more low-income patientswithout the clout to obtain higher payment rates from private insurers did not fare as well.
In contrast to hospitals with significant market power, many physician practices remained price-takers in negotiations with health insurers, with little, if any, increases in payment rates. However, in several markets, some practices could command sizeable rate increases, including large, hospital-owned or exclusively affiliated practices in Greenville and Boston and large specialty practices in Miami. For most physicians, practice expenses continued to grow as fast as or faster than commercial payment rates, providing little cushion against relatively flat Medicare reimbursement rates. Some physicians continued to protect earnings by increasing volume of services, especially in-office ancillary services, and trimming practice expenses. At the same time, physicians faced growing pressure to invest in costly electronic health records (EHRs), particularly with the introduction of federal EHR incentive programs.
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Hospital Expansion Strategies
ospitals continued to compete aggressively for patients and increase market share. Notably, strategies to expand geographic market areas, while not new, have become more widespread across most of the 12 communities since 2007. Generally, the hospital geographic expansion race involves pursuing well-insured patients beyond traditional market boundaries, whether in affluent suburbs or nearby urban and rural growth areas. To expand, hospital systems were building new capacity or acquiring or affiliating with existing providers in these areas to attract both physicians and patients to shore up referral bases and capture admissions, respectively.
In some areas, such as Greenville, hospital systems have opened full-service hospitals. In others, hospital systems have opened outpatient centers or freestanding emergency departments (EDs) that can be used in a hub-and-spoke model to direct referrals for more complex specialty and inpatient care to existing flagship hospitals. For example, in Cleveland, Indianapolis and Miami, hospital systems have built networks of outpatient centers that include offices for employed or closely aligned physicians, laboratory services, imaging equipment and sometimes urgent care clinics.
A relatively new phenomenon, freestanding EDs provide many of the same services as hospital-based EDs and the same opportunities for increased revenue in locations with well-insured populations. Freestanding EDs typically transfer patients needing advanced care to a systems nearest hospital, perhaps bypassing closer hospitals if the patient is medically stable. For example, Swedish Medical Center, Seattles largest hospital system, was planning a string of freestanding EDs in high-growth areas outside the city. At the same time, nearby smaller community hospitals were pursuing similar strategies to protect their market share.
While geographic competition has accelerated recently in such communities as Miami and Seattle, it has been underway longer in other communities, including Cleveland and Indianapolis. In those markets, the health care sector is becoming increasingly consolidated over widening regions, as independent hospitals and physicians join these expanding systems.
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Hospital-Physician Alignment
he acceleration of geographic expansion strategies complements longstanding hospital efforts to expand profitable specialty-service lines and stepped-up efforts to align more closely with physicians, with physician employment, in particular, increasing significantly. During the 2007 site visits, hospitals were employing specialists as part of broader service-line strategies or to fill gaps in emergency on-call coverage. In a few markets, including Cleveland, Greenville and Indianapolis, hospitals also employedor were aligned closely withlarge numbers of primary care physicians (PCPs).
Since 2007, in many communities, the trend of hospitals employing physicians has accelerated and broadened to include PCPs, as well as a wider range of specialists. Hospitals see physician employment and tighter alignment not only as a way to capture more specialty and hospital referrals in a fee-for-service payment system, but also as central to building the clinical and financial integration needed to succeed under potential new payment models, such as accountable care organizations (ACOs), that involve risk-sharing and reward quality and efficiency.
Physicians in most marketsfaced with financial pressures, difficulties recruiting younger physicians who often prefer employment in larger organizations, and growing uncertainty about the future under health reformwere more actively seeking the stability and security of employment in larger physician-owned or hospital-owned groups. While strained relations between hospitals and physicians in some markets have not dissipated, many hospitals reported that physicians were more frequently initiating discussions about employment. Some markets, such as Cleveland, Indianapolis and Greenville, appeared to be nearing saturation in hospital employment of PCPs and specialists, while in other markets, such as northern New Jersey and Miami, hospital and physician interest in employment lagged. In still other markets, competition between hospitals to employ physicians was heating up.
Hospitals were using an array of strategies to gain the loyalty of physicians choosing to remain independent, including providing physicians with administrative and health plan contracting support and offering financial and administrative support for EHR implementation. In a turnabout from earlier site visits and in response to declining profitability, specialty practices that had invested in ambulatory surgery centers and imaging centers in direct competition with hospitals have been selling these facilities to hospitals or entering joint ventures.
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Premium Hikes Attract Scrutiny
ealth plans inability to stem provider payment rate increases was most pronounced in markets like Miami, where a highly fragmented health plan sectorwith each plan holding relatively modest market sharelacks clout against increasingly consolidated hospitals and single-specialty physician groups. Rate increases also proved hard to contain in Boston, where a different dynamic was at play: Even more than consolidation, it is prestige and brand-name appeal that have conferred must-have status and the consequent ability to raise payment rates on select academic medical centers. While the pattern of high and increasing provider leverage was evident in many markets, it didnt hold true in all communities. Highly dominant plans in some marketssuch as Blue plans in Lansing and Syracusecontinued to keep provider rate increases relatively in checkeven when dealing, as in Lansing, with a highly consolidated hospital sector.
Large provider rate increases generally were passed on to employers in the form of premium increasesadding to the acute cost pressures of the economic downturn on employers. Steep premium hikes attracted scrutiny from many state regulators and other policy makers. Massachusetts and New York were among the states that imposed rate review on plans in the individual and small-group markets in 2010.
Views were mixed on the impact of rate review, with some observers concerned that it might lead some plans to exit a market segment already lacking in plan competition in some communities. In addition, many observers suggested that to make a meaningful impact on costs, regulators would need to focus on underlying provider payment ratesnot just insurer premiums. However, many questioned whether sufficient political will could be mustered to curb rates for high-cost hospital systems, given the prominent standing of these institutions in their communities and the potential impact of payment cuts on employment. Not only is the hospital sector among the largest employers in many markets, but it was among the very few sectors that grew during the recession.
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Consumer-Driven Health Plans Grow, But Consumerism Lags
n discussing trends in consumerism, it is important to distinguish the broad conceptconsumers having sizable financial incentives, information on prices, quality and treatment alternatives, and taking more responsibility for their own healthfrom a specific approach to benefit designconsumer-driven health plans (CDHPs) requiring large deductibles and often paired with a tax-advantaged savings account. The past few years have seen significant CDHP growth in most marketsoften starting from a negligible base and increasing to a modest share of enrollment overall, but a significant portion of small-group enrollment. For example, in Bostona market with historically rich benefitsCDHPs had grown to 15 percent of commercial enrollment and half of small-group enrollment by 2010. CDHP growth has been boosted primarily by cost pressures on employerspressures intensified by the recession, but also resulting from longer-term utilization and provider rate trends that health plans have had difficulty containing.
While CDHPs gained some traction in many markets, the broader consumerism movement did not keep pace. There was limited growth in the tools designed to inform and empower consumers, such as Web sites reporting hospital and physician price and quality information. More health plans, along with other private and public entities, have introduced or expanded such transparency initiatives over the last few years, but the number of programs providing actionable, provider-specific price and quality information remained quite limited. And, even when useful consumer-support tools were available in a handful of markets, evidence to date suggested that public awareness and use of these tools were limited.
Plan executives, brokers and benefits consultants in many markets observed that employers adopting CDHPs as the only benefit option were often focused primarily or solely on premium savings rather than promoting consumer engagement. Indeed, an increasingly common practice in some markets among employers seeking to keep premiums down, while also shielding employees from high out-of-pocket exposure, was to pair CDHPs with wraparound arrangements that reimburse employees for expenses incurred within the deductible portion of coverage. Health plans were struggling with this employer practice, arguing that it runs counter to the intent of CDHPs and noting that CDHP premiums were priced under the assumption that enrollees would be exposed to the full deductible. Plans in several markets recently began pushing back by implementing tiered CDHP pricing, making the lowest-priced products ineligible for wraparound coverage.
Many small employers adopting CDHPs purely for the premium savings were in no financial position to provide either wraparound coverage or to contribute to health savings accounts or health reimbursement arrangements. Since the start of the recession, small employers increasingly turned to CDHPs as an alternative to dropping coverage altogether. Employees with such coverage are exposed to the 'skin in the game part of consumerism, perhaps over-exposed [beyond] their ability to pay. but the broader notion of having them take on responsibility for [treatment decisions] or [provider] and lifestyle choicesthat hasnt been part of the equation, observed one California broker, echoing the views of market observers throughout the 12 communities.
When CDHPs were offered by large employers, they still tended to be offered as a choice rather than as a total replacement of existing benefit options. Many large companies adopting CDHPs were taking a somewhat cautious approach of introducing a CDHP alongside existing traditional product options and encouraging employees to choose the CDHP by offering substantial savings account contributions, sometimes combined with higher employer premium contributions. Once CDHP enrollment reached a significant level (such as 20% to 25%) after a few years, an employer might switch to the CDHP as the main option, requiring employees to buy up for traditional products.
One prominent exception to the pattern of large employers transitioning cautiously to CDHPs was Indianapolis, where pharmaceutical giant Eli Lilly joined early CDHP adopter Marsh Supermarkets in implementing total replacement. In addition, the state of Indianawhile prohibited by state law from offering only high-deductible plansadopted such strong premium incentives in favor of CDHPs that 85 percent of state employees were enrolled in these plans rather than traditional preferred provider organization (PPO) and health maintenance organization (HMO) options. This stood in marked contrast to most other markets, where public employers were not offering or even contemplating high-deductible plans as options. While less prevalent than in Indianapolis, CDHPs also had taken hold in Greenville, where high-profile employers like Michelin were moving toward total replacement.
Along with CDHP adoption, employers continued to increase patient cost sharing in traditional insurance products. In 2007, many market observers had suggested that patient cost sharing had reached its limit and that employers would have to find alternatives to moderate premium costs. With the recession, however, those views changed, and employers continued to pass more costs along to employees. One result was a blurring of distinctions between CDHPs and conventional PPOs, as average individual-coverage deductibles for the latter climbed to $1,000 in some markets. In markets with a historically strong HMO presence, employers continued to migrate from HMOs with traditional first-dollar coverage to HMOs with deductibles. In Orange County, for example, an estimated 80 percent of Kaiser Permanentes employer accounts reportedly offered an HMO with a deductible, either as the sole benefit offering or as part of a high-low strategy requiring the employee to pay the premium differential for first-dollar coverage.
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Wellness Expands
enerally, there was little innovation in health plan products across the 12 communities, but products featuring prevention and wellness components have proliferated since 2007, spreading well beyond products demanded by large, self-insured employers to target even small-group segments. Nearly all commercial products included a few basic wellness features built into the premium: online health risk assessments (questionnaires completed by employees or dependents about their own health and lifestyle), online action plans (suggestions for treatment or other interventions, typically based on responses to health risk assessments), and access to online resources, such as WebMD.
Beyond these basic features, plans in most markets offered fully insured products rewarding enrollees for completing health risk assessments and participating in lifestyle management programs. To a much lesser extent, plans in some markets had begun offering fully insured products rewarding enrollees for achieving health benchmarks on measures such as body mass index, blood pressure and cholesterol levels. While interest in wellness as a cost-containment strategy had spread well beyond large employers, actual adoption of wellness products by small and mid-sized employers remained modest, in large part because these products carry higher price tagsa particular challenge during the economic downturn.
Among large, self-insured employersmany that first implemented wellness strategies years agothere was an ongoing push to increase integration between wellness and disease management to create comprehensive care management approaches capable of dealing with the continuum of healthy to unhealthy behaviors. Despite the somewhat dampening effect of the recession, an increasing number of large private- and public-sector employers were taking a more direct role in care delivery by launching workplace health clinics, many of which provide primary care in addition to conventional wellness services. As one benefits consultant observed, Wellness is. the last tool thats left in the toolkit to control costs and manage care. so many [large] employers are really investing in it, pursuing it aggressively. Whether wellness programs will yield positive returns on investment, however, remains to be seen.
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Trading Benefits, Broad Networks for Lower Premiums
n contrast to wellness, which requires employers to invest up front in expectation of future payoffs, other product innovations introduced or retooled by plans in recent years typically featured limited benefits or limited provider networks in exchange for lower premiums. Limited-benefit products, often marketed as value plans, were targeted primarily at cost-conscious small employers and individuals. Reduced benefits were marketed in many different forms, including limits on the number of covered office visits, caps on prescription drug coverage (e.g., at $500), or copayments for office visits but high coinsurance (e.g., 50%) for all other services.
When limited-network benefit designs first attracted attention in the past decade, it was largely the result of large employers demanding these options from health plans as part of a value-based purchasing strategy. Narrow-network products exclude non-preferred providers from the network, while tiered-network products place these providers in a tier requiring higher patient cost sharing at the point of service. To date, however, these products have yet to gain traction in the large-group segment, in part because of strong provider pushbackincluding litigationand regulatory scrutiny regarding how health plans designate providers for inclusion in high-performance networks. In addition, many large employers have found the premium differential between narrow-network and full-network productstypically 10 percenttoo small to justify giving up broad provider choice.
Instead, it was in the individual and small-group markets where narrow-network and tiered-network products made headway in some markets. While nearly all such products focus on limiting physician networks, Blue Cross Blue Shield of Massachusetts took a different approach, offering products with hospital tiering in Bostona reflection of the impact of high and fast-growing hospital payment rates on already high premiums in this community. First introduced or revamped in 2010, these products impose large out-of-pocket penalties for using lower-tier (higher-cost) hospitals, including the renowned flagships of Partners HealthCare System and Childrens Hospital. According to media accounts, about one-third of individual and small-group accounts renewing in early 2011 switched to one of these tiered-hospital products.
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Safety Net Caught More People
he economic recession led to more people needing low- or no-cost health care at the same time the downturn reduced states and communities financial ability to support these services. While demand for safety net services had been growing for a number of years as the rising cost of health insurance resulted in slimmer benefits or loss of coverage, safety net providers saw demand jump during the recession as even more people became uninsured or covered by Medicaid.
Many of these people were newly poor patients who had not used the safety net before. The extent of need varied across communities: in 2009, the percentage of the population that was uninsured or had Medicaid coverage ranged from approximately 22 percent in Boston to 48 percent in Miami. Although challenged, safety net providers generally absorbed much of the increased demand and remained financially stable, often with the help of federal policy that protected Medicaid eligibility and increased direct funding to providers.
Changes in patient volume varied across communities and type of provider. Overall, volume increased most dramatically for primary care providers, including community health centers and free clinics. Safety net hospitals emergency department volume typically increased while inpatient admissions often were stable or dropped, possibly because of people postponing elective procedures. However, several safety net providers in Cleveland and Phoenix saw more stable or even declining volumes overall for certain services, which they attributed, respectively, to general population declines and an exodus of undocumented immigrants because of job losses and heightened fears of deportation. Health centers in Miami also typically saw stable or waning demand, which some respondents believed reflected the reduced ability of patients to pay income-related fees.
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Stimulus Dollars Stretch the Safety Net
n many cases, community health centers were able to treat additional patients because of an influx of funds from the 2009 American Recovery and Reinvestment Act (ARRA). These federal stimulus dollars helped health centers in five of the 12 communities become federally qualified health centers (FQHCs), a designation that brings enhanced Medicaid reimbursement and direct grants to support the costs of caring for the uninsured. For example, the Ingham County Health Departmentthe Lansing areas safety net hubachieved federal status for some of its clinics, and in Orange County, which previously had a sole FQHC organization for a community of approximately 750,000 low-income people, several more were established.
All existing FQHCs throughout the country received temporary grants to help meet the increased demand for services, and many received grants to add facilities and for capital projects. These grants allowed health centers to expand in several common ways, including increasing or renovating physical space, hiring staff, and purchasing new equipmentoften information technology to develop EHRs. While these expansions often focused on primary care, some FQHCsfor example, in northern New Jersey and Indianapolisexpanded dental and behavioral health capacity. Total ARRA funding for FQHCs varied across the 12 communities, largely correlated with their number of health centers: from just over $1 million for the one FQHC in Little Rock to approximately $80 million across the 31 FQHCs in Boston.
In contrast, non-FQHC clinics and safety net hospitals did not directly benefit from stimulus funding. Ineligible for ARRA grants, free clinics instead were reliant on continued support from volunteers, grants and philanthropygiving increased for some clinics and declined for others. Although ARRA increased disproportionate share hospital (DSH) payments to states for fiscal years 2009 and 2010the funds are intended to support hospitals serving a high percentage of low-income patientssafety net hospitals reported that additional DSH funding typically shored up state Medicaid budgets more generally instead of being passed on to hospitals. In fact, hospitals in several communities reported a decline in DSH payments in recent years. Yet, both inpatient and outpatient safety net providers in some communities continued to receive funding to treat uninsured people through programs largely or partially funded through DSH mechanisms or Medicaid waivers, including the Ingham Health Plan in Lansing, the Medical Services Initiative in Orange County and the charity care programs in New Jersey.
ARRAs protection of the Medicaid programrequiring that states maintain Medicaid eligibility at July 2008 levels as a condition for receiving a higher rate of federal matching fundsindirectly helped both hospitals and health centers and prevented states from making more severe Medicaid cuts. Without these so-called maintenance-of-effort requirements, providers likely would have lost revenue as patients lost coverage. Instead, Medicaid enrollment grew significantly since 2007, and some providers proportion of Medicaid patientscompared to uninsured patientsincreased, improving their financial position. ARRA did not safeguard Medicaid provider reimbursement levels, and about half of the communities experienced provider payment rate reductions, but states still had to provide enhanced Medicaid payment rates to FQHCs. And, in some communities, including Cleveland and Lansing, new or increased hospital taxes that gained matching federal Medicaid dollars and were then redistributed to hospitals helped alleviate these cuts.
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Budget Deficits Take Toll
ow state and local budget deficits affected health care programs and funding for providers also varied. States, such as Washington and New Jersey, that had extended public insurance programs to cover additional groupsincluding new or undocumented immigrants, childless adults, and higher-income parentstypically pared back this coverage. In addition, some respondents believed that additional federal dollars for FQHCs supplanted some state and local funding for safety net providers. Indeed, most communities saw state funding sources for health centers declineeven completely eliminated in Phoenix and Orange Countyand the few communities, for example, Seattle and Miami, where health centers receive direct local funding typically saw reductions.
Although local tax revenues, which support county hospitals in half of the communities, declined, local officials typically allocated a greater proportion of available funds to these hospitals so that funding levels were at least stable. Maintaining these public expenditures can be financially advantageous for the community as a whole because the funds often can secure federal Medicaid matching funds. By also pursuing internal cost-containment strategies, most safety net hospitalspublic and privateweathered the recession, and the financial situation of some even improved from 2007. Miamis public hospital, however, was in significant financial distress, reportedly because of management issues, declining local tax-revenue support and significant growth in uncompensated care costs in this community where almost a third of the population is uninsured.
In an effort to serve more people in a cost-effective way, community safety nets redoubled efforts to advance the medical-home model that has attracted national attention as a goal for all patients. Respondents reported that community health centers embody this approach, given that many health centers serve as a one-stop shop for many additional social services and use health care teams to coordinate patients care and manage transitions to other providers. A Seattle FQHC director expressed a common sentiment, We are the medical-home model. Its new for everybody else, but its what weve been doing forever.
Still, many safety net providers were unable to keep up with increased demand for certain services. Capacity for services that have long been the most difficult for low-income people to accessspecialty, dental and mental health caretypically remained flat or even declined in some communities. Several states cut or reduced coverage of optional Medicaid benefitsespecially adult dental services, but also podiatry, vision and other careand funding for state psychiatric institutions and community-based mental health services.
Although the safety net remained largely intact and even expanded in some areas during the economic downturn, providers may face mounting challenges depending on how long the recessions effects linger and how implementation of national health reform proceeds. Enhanced federal Medicaid matching funds to states are slated to phase out by mid-2011 and, although the National Conference of State Legislatures reports state revenues are improving, more than half of states were projecting budget deficits for fiscal year 2012. While the federal Patient Protection and Affordable Care Act (PPACA) required states to maintain Medicaid eligibility levels, loss of federal Medicaid funds could cause states to cut other funds that support the safety net.
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Bracing for Health Reform
roviders, while positive about the potential to treat newly insured patients, were anxious about the prospect of inadequate reimbursements from Medicaid and from health plans offered through state insurance exchanges scheduled to come on line in 2014. They speculated that primary care physician supply, already tight in some markets, would likely be insufficient to handle additional demand from newly insured patients, especially if physicians are unwilling to treat patients because of low payment rates. Inadequate physician supply, in turn, could exacerbate existing pressures on ED capacity.
Hospitals and physician groups also were exploring how to respond to expected Medicare payment reforms, including the introduction of ACOs and other forms of risk-based payment. Some hospitals and large physician groups were working to develop ACOs. But, in most markets, the early reaction to health reform was increased anxiety about whether payment rates for newly covered patients would be adequate and coming reductions in the growth of Medicare payments, heightening existing pressures to engage in hospital-physician alignment activities, health information technology adoption and cost-cutting measures.
A key concern from safety net respondents was the extent to which support will continue for low-income people who remain uninsured even after the coverage expansions slated for 2014. Although ARRA grants are ending, FQHCs are starting to receive additional funds under the health reform law$11 billion over five years to double the number of patients served by 2015. However, additional community health center funding has already been scaled back, with $600 million cut this year during the recent budget compromise to keep the federal government from shutting down. Likewise, recent reports indicate some additional drops in state or local public funding for safety net providers, as well as drops in private foundation support and donations that non-FQHC clinics rely on. Also, providers feared that declining DSH funds starting in 2014 may exceed the relative increase in revenues that newly insured patients bring. Indeed, safety net hospitals in Bostonwhere state health reform in 2006 preceded national reformstruggled financially after much of their direct funding was reallocated to subsidize insurance coverage.
Safety net providers in communities with large Latino populations, including Orange County, northern New Jersey and Miami, were particularly concerned about future resources for the safety net. The Congressional Budget Office estimated undocumented immigrants will account for a third of the 23 million people expected to remain uninsured after full implementation of PPACA. With undocumented immigrants comprising a greater proportion of the uninsured than before, some respondents worried that public and private funding for services for the uninsured could evaporate.
Health plans, while looking forward to opportunities to expand enrollment substantially under national reform, nearly all voiced strong concern about the potential for adverse selectionattracting sicker-than-average enrolleesin the insurance exchanges. The individual mandates penalties for lack of insurance were widely perceived as too weak, leading many plan respondents and market observers to expect that a substantial portion of healthy people will remain on the sidelines and out of the exchanges. Another concern for many plansespecially national for-profit planswas complying with minimum medical-loss ratios (MLRs)the percentage of premium spent on patient careand additional state and federal regulatory requirements. However, the degree of concern about additional regulation varied widely across markets, with not-for-profit local and regional plans in highly regulated states often already meeting or exceeding MLR and other regulatory requirements imposed by national reform.
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Data Source
Every two-three years, HSC conducts site visits to 12 nationally representative communities as part of the Community Tracking Study to interview health care leaders about the local health care market and how it has changed. The communities are Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y. Almost 550 interviews were conducted in the 12 communities with representatives of health plans, hospitals, physician organizations, major employers, benefit consultants, insurance brokers, community health centers, consumer advocates and state and local policy makers between March and October 2010. This Issue Brief reflects the high-level key findings from these interviews. In the coming months, HSC researchers will complete in-depth analyses on a range of topics that will be published as HSC Issue and Research Briefs and in peer-reviewed journal articles.
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Community Tracking Study Site Visit Researchers
HSC conducted its 2010 site visits in collaboration with researchers from various other research organizations. Site visit researchers are organized into three teams, each covering a major area of interest.
Private SectorHa T. Tu, Center for Studying Health System Change (HSC) - Team Leader
Jon B. Christianson, University of Minnesota - Lead Researcher
Grace Anglin, Mathematica Policy Research (MPR)
Gary Claxton, Kaiser Family Foundation
Genna R. Cohen, HSC
Elizabeth Docteur, HSC
Divya Samuel, HSC
Tracy Yee, HSC
Provider SectorJoy M. Grossman, HSC - Team Leader
Robert A. Berenson, Urban Institute - Lead Researcher
Amelia M. Bond, HSC
Emily Carrier, HSC
Dori Cross, HSC
Marisa K. Dowling, HSC
Paul B. Ginsburg, HSC
Elizabeth A. November, HSC
Ann S. OMalley, HSC
Public SectorLaurie E. Felland, HSC - Team Leader
Peter J. Cunningham, HSC - Lead Researcher
Ian Hill, Urban Institute
Aaron Katz, University of Washington
Ralph C. Mayrell, HSC
Caroleen W. Quach, MPR
Lucy B. Stark, HSC
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The Needle Drop's Anthony Fantano recently [disagreed][http://www.youtube.com/watch?v=VuFWZmcH-nY] with the music documentary PressPausePlay's argument that there is an oversaturation of mediocre music on the interweb drowning out all the real talent out there. I would have to agree with Mr Fantano - I have discovered a huge amount of talent while surfing the web in the past.
Enter Internet Forever then who, since forming on the Live Journal message boards, were unfairly pigeonholed in the numbers of what might well be classified as mediocre, lo-fi bands cluttering up the internet. Once they released their debut singles 'Break Bones' and 'Cover the Walls' though, it was clear that this was a talented trio far ahead of the pack they had been placed in. Both tracks are glorious pieces of fuzzy indie-pop radiating warmth and personality other bands lacked; their inclusion on this debut long player continues to reaffirm that fact. In the four years since the band formed, it's clear that they have gone a long way from their bedroom recording days and have become a more tightly knit and polished unit.
Nonetheless, the band has retained the character and charm that made them so appealing in the first place. '3D', for example, sees vocalist Laura Wolf regret an online relationship as she spits: "Refreshed your page a hundred times / To see if you'd updated / Then I looked at what you'd written on the message board / And everything you said I hated." The venom continues to seethe on 'Centre of Your Universe' as the band curses an impossible relationship: "We want to be the centre of your universe but someone above won't let us through / We want be the centre of your universe but someone above us is saying that'll never do."
Such bite is made more propulsive thanks to the engineering talents of James Rutledge (MGMT, Radiohead, The Kills) and Dreamtrack (Foals, T3ETH). The short opener 'Golden Temple' sounds threateningly like a helicopter blade closing in whilst the noise-rock freak out of 'I'll Sleep When I'm Alive' is particularly volatile. The real cherry on top of this hyperactive cake comes in the form of highlight 'Page of Books.' Complete with childish xylophones, a flimsy structure and full on group chanting, Internet Forever may as well be screaming: 'HEY EVERYONE, LOOK AT US! WE'RE PLAYING A LOS CAMPESINOS! NUMBER HERE!' And they do it pretty bloody well too.
Of course, there is still an element of 'bubble-gum cuteness' throughout – notably 'Happy New Year' which has a dainty little synth which probably could never hurt a fly. But for the most part, Internet Forever display an explosive energy which is just shouting out to be heard… and everyone would do perfectly well to give them their full and undivided attention.
7Alex Yau's Score
10User Score

subset: commoncrawl


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Who would ever imagine that sand dunes could look so incredible? In this beautiful image, sand trapped in an impact crater in the Red Planet's Moachis Terra region have been sculpted by the winds of Mars into a vast and variegated landscape.
But photos like this have far more to offer than their beauty — they also allow scientists to study one of the fastest, most dynamic geological processes in the universe, providing us with incredible insights into Mars' history.
More than 21,000 images have been captured by NASA's HiRISE telescope since it began taking photos of the Red Planet's surface in late 2006. Photos like the one up top [hi-res available here] are of particular interest to scientists studying what are known as "aeolian processes" — i.e. the study of landforms formed by wind (Aeolus is the wind god in Greek mythology).
Unlike many other geological processes, which can take hundreds of thousands of years to change in any dramatic or visibly noticeable way, the wind-crafted sands of Mars' surface are continually changing at a pace so rapid, we've managed to visualize their movement even in the few short years we've been observing them.
How fast various "aeolian bedforms" (dunes and ripples) migrate across the planet's surface, how quickly they settle into the planet's various topographical features, whether or not some bedforms even migrate at all — these are just a few examples of the questions planetary scientists are using images like this to understand; and the answers they find will help us make sense of Mars' geological and climatological past, present, and future.
[Via NASA]


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Half of food produced worldwide is wasted, study finds
Up to half of the food produced worldwide never makes it into a consumer's mouth, according to a new report.
That's as much as 2 billion tons of grub that's wasted, according to a study released Thursday by Britain's Institution of Mechanical Engineers (hat tip to the Guardian).
Part of the problem is in the supply chain, in which inefficient agricultural practices, inadequate infrastructure, limited transportation options and poor storage capacity lead to squandered harvests and misused land, water and energy resources, according to researchers.
But consumers and retailers are also to blame, according to the group.
Overly strict sell-by dates means food is often thrown out before its time, the study says. The preponderance of buy-one-get-one-free offers causes households to buy more food than they can eat before it spoils. And customer demand for cosmetically perfect fruits and vegetables results in piles of scratched or misshapen — but still nutritious — produce ending up in the trash.
Quiz: How well do you remember 2012?
In Britain, some 30% of vegetable crops are left unharvested because they're not pretty enough, according to the report. In Europe and the U.S., consumers dump half of the food they buy, researchers said.
That's despite the nearly 1 billion people who go hungry globally, and the additional 3 billion mouths to feed expected by 2075.
"The amount of food wasted and lost around the world is staggering," said Dr. Tim Fox, who heads up the energy and environment division at the engineers' group.
In a separate report this summer, the Natural Resources Defense Council said that Americans waste up to 40% of the country's food supply, an a cost of $165 billion. That's 20 pounds per person per month, according to the advocacy group.
Americans toss out as much as 40% of their food, study says
Food is getting more expensive internationally, says World Bank
In SoCal areas, a quarter of families can't afford enough food: report


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Signs of approaching "sudden" cardiac arrest, an electrical malfunction that stops the heart, usually appear at least a month ahead of time, according to a study of middle-age men in Portland, Ore.
"We're looking at how to identify the Tim Russerts and Jim Gandolfinis — middle aged men in their 50s who drop dead and we don't have enough information why," said Sumeet Chugh, senior author of the study and associate director for genomic cardiology at the Cedars-Sinai Heart Institute in Los Angeles.
Some 360,000 out-of-hospital cardiac arrests occur each year in the United States, largely involving middle-aged men, with only 9.5 percent surviving, according to the American Heart Association.
Patients can survive if they are given cardiopulmonary resuscitation (CPR) immediately and their hearts are jolted back into normal rhythm with a defibrillator.
Earlier clinical trials have focused only on symptoms or warning signs within an hour of such attacks. But Chugh's study set out to determine whether signs and symptoms occurred as much as a month before sudden cardiac arrests.
Researchers went back and examined medical records of men 35- to 65-years-old after they had out-of-hospital attacks. In addition, paramedics reaching the scene of fatal attacks asked family members what signs and symptoms the patient may have had in preceding weeks.
Among 567 men who had "sudden" arrests, researchers determined 53 percent had symptoms beforehand. Among those with symptoms, 56 had chest pain, 13 percent had shortness of breath and 4 percent had dizziness, fainting or palpitations.
About 80 percent of symptoms happened between four weeks and one hour before the cardiac arrest, researchers said. And although most men had coronary artery disease, just half had been tested for it before their attacks.
"The findings were entirely unexpected," Chugh said. "We never thought more than half of these middle-aged men would have had warning signs so long before their cardiac arrests. Previously we thought most people don't have symptoms so we can't do anything about it."
Chugh said most people who have the same kinds of symptoms don't go on to have cardiac arrests.
"Even so, they should seek medical care," he said. "The message here is, if you have these signs or symptoms, please don't ignore them: seek health care."
Chugh said he and his colleagues are also attempting to identify people at risk by comparing biologies of those that have had sudden cardiac arrests with sample populations in Portland that have never had cardiac arrests.
The new findings, from the 11-year-old "Oregon Sudden Unexpected Death Study," were presented on Tuesday at the annual scientific sessions of the American Heart Association being held in Dallas.
The researchers are conducting similar studies among women. The ongoing study is being funded by the U.S. Centers for Disease Control and Prevention, AHA and the Doris Duke Charitable Foundation.


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Voice part included (German, English). Franz Schubert (1797 - 1828) was an Austrian composer. He wrote some 600 Lieder, nine symphonies, liturgical music, operas, and a large body of chamber and solo piano music. He is particularly noted for his original melodic and harmonic writing.


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[310 U.S. 318, 319] Robert Jackson, Atty. Gen., and Mr. Charles Fahy, of Washington, D.C., for petitioner.
Mr. Harry Parsons Cross, of Providence, R.I., for respondent, Bradford Dyeing Ass'n.
Mr. William G. Feely, of Washington, D.C., for Bradford Dyeing Ass'n Employees' Federation Local Union No. 16, intervener, respondent.
Mr. Justice BLACK delivered the opinion of the Court.
The Circuit Court of Appeals declined to decree effective enforcement of an order of the National Labor Relations Board upon the ground that the Board's order, in material respects, rested upon findings that were not supported by substantial evidence. 1 Cir., 106 F.2d 119. [310 U.S. 318, 320] In its petition for certiorari, the Board took sharp issue with the Court of Appeals, asserting that some findings upset by the court were supported not merely by substantial but by 'uncontradicted' and 'undisputed evidence.' The petition also pointed out that the court's opinion was 'ambiguous and inconclusive' and 'left unclear the court's holding as to whether the Board had jurisdiction.' Our inspection of the court's opinion and decree disclosed that the court deemed the Board to be wholly lacking in jurisdiction. Nevertheless, the Board was ordered to proceed in accordance with the opinion which concluded with the indecisive statement that 'if the case should not be dismissed for lack of jurisdiction' a large part, but apparently not all, of the Board's order should be vacated. The court's decree did not direct enforcement even of those parts of the Board's order not expressly vacated. The Board's petition further pointed out that its motion for rehearing in order to clarify the question of its jurisdiction and to establish the status of 'those portions of the Board's order which the court neither vacated nor enforced' was denied without explanation. Because the Labor Board's petition in challenging the action of the Court of Appeals thus raised questions of grave public importance affecting the administration of the National Labor Relations Act, 29 U.S.C.A. 151 et seq., and judicial review as provided in the Act, we granted certiorari. 1
This proceeding was initiated upon charges filed by the Textile Workers Organizing Committee of the C.I.O. Thereupon, the Labor Board served a complaint and notice of hearing on the Bradford Dyeing Association (U.S.A.), respondent here.
In the complaint, it was alleged that respondent in order to discourage membership in the C.I.O., had discharged and refused to reinstate its employees, Edward [310 U.S. 318, 321] Nelson and Percy Schofield, because of their affiliation and activities in the Textile Workers Organizing Committee of the C.I.O., (T.W.O.C.); respondent had dominated and supported the Bradford Dyeing Association Employees' Federation, a labor organization, and had refused to bargain collectively with its employees through the T.W.O.C. after a majority had selected it as their bargaining representative.
The Board's jurisdiction was unsuccessfully challenged on the ground that respondent's business involved no activities in or affecting interstate commerce within the meaning of the Act. And, answering, respondent alleged that Schofield was discharged because he smoked during working hours; 'that ... Nelson was not discharged, that he was insubordinate and defiant, that he did not work and refused to work during the times when he was supposed to be working, that he was on the premises during hours when he was not supposed to be on the premises of respondent and was taking up the time of other employees who were supposed to be working during such time, that ... Nelson went upon a vacation and has not returned to work after such vacation nor made any statement of his readiness to return to work or made any request that he be put to work again'; that respondent had not dominated or coerced the Federation; and that any labor disputes at its plant were attributable to the conduct of the T.W.O.C.
The Federation was allowed to intervene in the extensive hearing held by the Board.
After this hearing, the Board found that 'a labor dispute' in respondent's plant would widely affect 'the flow of commodities in interstate commerce', with consequent jurisdiction in the Board, and that the charges of the complaint had been substantiated.
The Board accordingly ordered respondent to cease and desist from (1) interfering, or coercing its employees [310 U.S. 318, 322] in the exercise of their rights to self-organization; (2) dominating and interfering with the Federation or any other labor organization; (3) discouraging membership in the T.W.O.C.; (4) refusing to bargain collectively with the T.W.O.C.; and (5) ordered respondent affirmatively to offer reemployment to Schofield and Nelson and to make them whole, to withdraw all recognition from and completely disestablish the Federation, to bargain collectively with its employees through T.W.O.C., and to post the usual notices throughout its plant stating that the company would cease its unlawful and unfair labor practices and would treat its agreement with the Federation as of no effect.
In its final decree the Circuit Court of Appeals directed that 'until a new election has taken place by order of the Board, and the employees have expressed their preference as to what group or body shall represent them in any labor dispute between them and the respondent, the order of the Board except as to paragraphs 1, 2 and 3 of the case and desist portion of the order, and the entire paragraph 5 ordering affirmative action shall be vacated, the Board then to proceed in accordance with (the opinion passed down this day).' (106 F.2d 125.) As phrased, the decree is not clear but apparently the court vacated subdivisions (4) and (5) of the Board's order. The court's opinion did make clear that under its decree the company was left free to bargain collectively with the Federation and to decline to bargain with the T.W.O.C. Discharges of Schofield and Nelson were approved and the company was released from publishing notices which, if warranted, were 'essential if the employees were to feel free to exercise their rights without incurring the company's disfavor.' 2 Although those portions of the Board's order prohibiting the company's interfering with [310 U.S. 318, 323] its employees' union affiliations were not expressly set aside or modified, neither were they ordered enforced. 3 Thus the court's decree gave the Board's order no effect at all.
It did not explicitly so decree, but the Court of Appeals evidently was of the view that evidence was lacking upon which the Board could have found that respondent's business was in or affected interstate commerce. The court expressly found a lack of evidence to support the Board's conclusion that Schofield and Nelson were discharged for union activities and stated its belief that Schofield was discharged for smoking in the plant and Nelson for insubordination, and that 'the finding by the Board that the T.W.O.C. had a majority of the employees of the respondent signed up even to become members of a union under that name is without substantial evidence on which to rest.'
Without specifically passing upon the Board's finding that respondent had unlawfully dominated the Federation, the opinion of the court stated, ' ... Assuming that the president or officers of the respondent influenced its employees to join the Federation, so called, it does not appear by clear and substantial evidence that a majority of the employees ever joined, or indicated an intent to join, the T.W.O.C., ....' (Italics supplied.) Since the court [310 U.S. 318, 324] did not vacate that part of the Board's order directing the company to discontinue domination of the Federation, we might infer that the court accepted the Board's finding that the Federation had been so dominated. But this inference is opposed by the court's action in vacating the order of disestablishment. The uncertainty in which the court has left the questions of jurisdiction and company domination of the Federation makes necessary a review of the evidence on both, along with other evidence which we think amply demonstrates the justification for the Board's order in every respect.
First. As to Jurisdiction.
A major portion of the opinion of the court below is devoted to its expression of doubts about the Board's jurisdiction, i.e., 'there is no substantial evidence to warrant a finding that the transportation of these materials by the respondent was ever in interstate commerce'; 'there is also lacking substantial evidence that 40 percent of the supplies consisting of chemicals and dyes, which were contracted for in Rhode Island and delivered by the sellers to the respondent's plant in Bradford, were transported by the respondent in interstate commerce, or that they were used by the respondent except at Bradford, though the Board assumed without evidence that they were shipped by the respondent in interstate commerce, but its assumption lacks substantial evidence on which to rest, that would compel this court to accept it as a fact'; 'The respondent, according to uncontroverted testimony, neither sells, transports nor arranges for transportation of the goods into or out of Rhode Island in interstate commerce, which is done in each instance by the customer, ...' ; and 'The Board apparently assumed that the respondent transported goods to its plant and from it, which the uncontroverted evidence disclosed were not the facts.' Referring to waste products which respondent sells in interstate commerce, the court noted that they did [310 U.S. 318, 325] not 'exceed 1 percent of the total goods processed' and said that they were but 'a mere incident (of the business) and to which the maxim de minimis might well be applied, even by the National Labor Relations Board.' And the conclusions of the opinion were only stated subject to the condition 'If the case should not be dismissed for lack of jurisdiction.'
There was evidence before the Board which showed:
That this evidence was abundantly sufficient to justify exercise of jurisdiction by the Board is not now open to controversy. It is settled that the Act is applicable to a processor, who constitutes even a relatively small percentage of his industry's capacity,4 where the materials processed are moved to and from the processor by their owners through the channels of interstate commerce,5 and it is not material, as the court below thought, that respondent's customers might be able to secure the same services from other Rhode Island processors if a labor dispute should stop the interstate flow of materials to and from respondent's plant. Since the purpose of the Act is to protect and foster interstate commerce, the Board's jurisdiction can attach, as here, before actual industrial strife materializes to obstruct that commerce. 6
In its answer to the Board's complaint, the company contended that Nelson was not discharged April 3, 1937, but was merely 'laid off', and on April 2, 'went upon a vacation' and did not return or indicate a willingness to go back to work. However, the company insists, as it has throughout, that Nelson was not a diligent worker and was insubordinate; that he trespassed upon company property after work hours Thursday, April 1st; that 'one or two mornings that week he started work a little late [310 U.S. 318, 327] and quit a little early'; that he did not start work Saturday, April 3, until 7:30, a half hour late.
Some of the evidence supporting the Board's finding that Nelson was actually discharged for union activities on April 3, was:
From the testimony of the T.W.O.C. official in question, a T.W.O.C. Director for Rhode Island, Summersby would not rehire 'especially Mr. Nelson.' And Summersby himself stated that he told the Federal Conciliator, 'I couldn't take back either of them because it would break down the discipline of our plant.'
Nelson's foreman testified as a witness for respondent-
Third. Discharge of Schofield.
The court below saw no evidence supporting the Board's finding that this employee was discharged for union activities, and accepted the company's contention that he was discharged for smoking in the plant contrary to rules. Respondent admits that Schofield was discharged.
Schofield, a machine operator, or 'jigger', testified-
As told by the boss dyer who found Schofield smoking-
One of the fellow employees present in the locker-room where Schofield was found smoking, stated that he also had been smoking but was not doing so when the boss dyer came in, and that the third man was smoking at that time but wasn't observed. He got the impression, then, that the boss dyer said something to the effect that he at last 'had' Schofield after having been after him for some time. He 'had never seen ... (the boss dyer) go to the locker room' before. [310 U.S. 318, 333] Summersby testified that he had been told by Schofield that he was 'interested in organizing the C.I.O.'; and that he discharged Schofield for smoking.
Fourth. Domination of the Federation.
As already noted, the Court of Appeals' opinion did not especially pass upon this contention. Since, however, the Court did not enforce the Board's order to cease dominating and to disestablish the Federation, as we think it should have, appropriate evidence on this issue will be pointed out.
A machinist, employed eleven years by respondent, testified-
From testimony of other employees, it appeared that-
An employee testified-
Another employee supplied evidence that a week or two after Nelson was fired, the timekeeper took him to see Summersby, who asked about a C.I. O. card which had been on the back of this employee's car, and that Summersby then 'said he wouldn't recognize it' and could close the plant down.
The financial Secretary of the Federation stated-
The first vice president of the Federation testified-
T.W.O.C.'s State Director for Rhode Island stated-
According to the company's vice president-
One of the men present when Schofield was found smoking testified that a salaried employee who reports 'things which are done wrong' came around and asked everybody if he had joined the local union; at the meeting in the shipping room, Summersby said he would not recognize the C. I.O. but would recognize a local; the witness was paid for the fifteen minutes spent at that meeting; the men were told by the time-keeper that they would be so paid. An official of the Federation said, 'The impression was that Mr. Summersby probably wouldn't recognize' the C.I.O.; this official was 'one [310 U.S. 318, 338] of the first' organizers of the Federation and conveyed to people the impression that Summersby wouldn't recognize the C.I.O.
As related by Summersby, president and general manager of respondent-
Fifth. Designation of T.W.O.C. as bargaining agent.
The court below found no substantial evidence to support the Board's finding that a majority of respondent's employees joined the T.W.O.C., or that 'the T.W.O.C. ... ever came into actual existence with authority to negotiate a contract with the respondent.' Much of the testimony already referred to bore upon the genesis of T.W.O.C. at respondent's plant. [310 U.S. 318, 339] Schofield said:
Nelson stated that he told the timekeeper, on April 2, 'It's all over but the shouting .... We have well over sixty per cent signed up all ready.' And from the testimony of an officer of the Federation it appeared that the C.I.O. drive resulted in a number of signatures, and that both organizations could possibly claim fifty-one per cent of the employees signed up.
As explained by the T.W.O.C. State Director-
The T.W.O.C. Director's Secretary stated that the T.W.O.C. cards were brought in before April 12. It was agreed at the hearing that, after respondent checked against the original signed cards, T.W.O.C. had a list of four hundred and eighty-two names taken from those cards. And it was stipulated that these cards were signed 'on or before April 10, 1937.'
Shift in membership.
Respondent has contended before the Board, as here, that if the T.W.O. C. did actually represent a majority [310 U.S. 318, 340] of its employees on April 4 (as the Board found), a shift in membership had given the Federation a majority when the company on April 9 recognized it as exclusive bargaining representative. However, the Board found that 'the record is clear that, had it not been for the unfair labor practices of the respondent in organizing and fostering the Federation and in persuading, intimidating and coercing its employees to join the Federation and leave the T.W.O.C., the respondent's employees would have remained members of the T.W.O.C.' In view of the substantial support in the evidence for the Board's findings that the company intimidated and coerced its employees and dominated the Federation, the Board properly concluded that 'The unfair labor practices of the respondent cannot operate to change the bargaining representative previously selected by the untrammelled will of the majority.' 7 And, accordingly, the Board was justified in its finding 'that on April 4, 1937, and at all times thereafter, the T.W.O.C., pursuant to Section 9(a) of the Act, was the exclusive representative of all the employees in the appropriate unit for purposes of collective bargaining ....'
As one of the apparently alternative grounds of its decision, the Circuit Court of Appeals declared the Board without authority to order reinstatement of Nelson and Schofield because of so-called unlawful conduct and the alleged incitement of a 'sit down' strike within the meaning of the Fansteel case. 8 The opinion stated that 'Nelson even threatened truck drivers delivering materials to the plant with violence, and to destroy spur tracks over which materials were delivered to the plant. ... The [310 U.S. 318, 341] affirmative action that is authorized is to make these remedies effective in the redress of the employees' rights, to assure them self-organization and freedom in representation, not to license them to commit tortious acts or to protect them from the appropriate consequences of unlawful conduct. We are of the opinion that to provide for the reinstatement or reemployment of employees guilty of the acts, which it is not denied were committed in this instance, would not only effectuate any policy of the Act, but would directly tend to make abortive its plan for peaceable procedure.'
We find no such issue raised by respondent's pleadings before the Board. Respondent made request for special findings by the Board, but included none that Nelson and Schofield had been guilty of any unlawful conduct. Nelson categorically denied having made threats of violence. The court was apparently referring to the testimony of a truck driver which appears in the record. An objection of the Board's representative to the introduction of this particular testimony was overruled by the trial examiner when respondent's attorney made the following statement: 'If your Honor please, may I point out that while Mr. Nelson was on the witness stand in cross-examination I asked him if he did not say certain things at this time and place, that this witness has been referring to, which the witness Nelson denies. The testimony of this witness that Nelson did say those things is in contradiction of Mr. Nelson's testimony and is clearly admissible as tending to impeach the veracity of Mr. Nelson's testimony. Aside from that I also submit it as bearing on the type of conduct and the attitude of the representatives and organizers of this T.W.O.C. getting membership and conducting the affairs of this organization.'
This truck driver's helper testified that on the morning of April 8, after Schofield and Nelson had been laid off, he saw Nelson, Schofield and a third 'little fellow from the [310 U.S. 318, 342] C.I.O.' 'outside the mill yard.' He noticed Nelson 'going up and down motioning ... Going like this (illustrating by waiving arms, squatting and standing.)' As this truck driver recollected, Schofield was not 'doing anything.' 'If anybody was looking out the east door they could' see Nelson or Schofield moving their hands that morning; Nelson 'made a motion to sit down, that is all,' out 'on the main road going to the plant.' He 'couldn't say that' any workers would have seen Nelson; he 'couldn't say that, whether they could see out or not. I don't know.' An employee, not Nelson or Schofield, who 'went through the department shouting 'Sit-down strike," was taken for an automobile ride by the company's vice president, talked to, given lunch and sent home to bed without loss of pay and was still working for the company at the time of the hearing. When asked, 'You remember you said, 'Well, we can blow up the railroad?", Nelson answered, 'No, absolutely not.'
In vacating the Board's order of reinstatement on the ground that undenied evidence showed that Nelson and Schofield had, after their unlawful discharge, incited or threatened unlawful conduct, the court acted without any justification.
Congress has placed the power to administer the National Labor Relations Act in the Labor Board, subject to the supervisory powers of the Courts of Appeals as the Act sets out. If the Board has acted within the compass of the power given it by Congress, has, on a charge of unfair labor practice, held a 'hearing', which the statute requires, comporting with the standards of fairness inherent in procedural due process, has made findings based upon substantial evidence and has ordered an appropriate remedy, a like obedience to the statutory law on the part of the Court of Appeals requires the court to grant enforcement of the Board's order. Until granted such enforcement, the Board is powerless to act upon the parties [310 U.S. 318, 343] before it. And the proper working of the scheme fashioned by Congress to determine industrial controversies fairly and peaceably demands that the courts quite as much as the administrative body act as Congress has required.
Mindful of the separate responsibilities Congress has imposed upon the Board and the courts, we have carefully scrutinized this entire record. Within the range of our examination has appeared not merely the testimony but also the procedure followed from the filing of the charge before the Board to final decree of the Court of Appeals. The Board and its representatives solicitously guarded respondent's and intervenor's right to a full and fair hearing; manifested liberality in ruling upon evidence proposed by both sides; and conducted the proceedings in a manner calculated to bring about a just result. And as we have pointed out, substantial evidence supported the result which the Board did reach. 9 Notwithstanding, the court below declined to order enforcement of the Board's order, and the implications of its opinion are that the Board without a proper regard for either the limitations on its power or the evidence made findings all of which had no substantial support.
But in reaching this conclusion the Court of Appeals itself failed to give proper regard to the evidence which was before the Board, which appeared in the record before the court and which we have set out in this opinion. In refusing to enforce the Board's order, the court exceeded the power given it. The cause is reversed and remanded with directions to enforce the Board's order without conditions or qualifications.
Mr. Justice McREYNOLDS took no part in the consideration or decision of this case.
[ Footnote 1 ] 308 U.S. 549 , 60 S.Ct. 386, 84 L.Ed. --; cf. National Labor Relations Board v. Waterman Steamship Co., 309 U.S. 206 , 60 S.Ct. 493, 84 L.Ed. --.
[ Footnote 2 ] National Labor Relations Board v. The Falk Corp., 308 U.S. 453, 462 , 60 S.Ct. 307, 312.
[ Footnote 3 ] Section 10(e) of the National Labor Relations Act gives the Board power to petition any Circuit Court of Appeals of the United States for the enforcement of its order; grants these courts exclusive jurisdiction and provides that 'Upon (the Board's filing a transcript of the entire record in the proceeding), the court shall cause notice thereof to be served upon such person, and thereupon shall have jurisdiction of the proceeding and of the question determined therein, and shall have power to ... make and enter upon the pleadings, testimony, and proceedings set forth in such transcript a decree enforcing, modifying, and enforcing as so modified, or setting aside in whole or in part the order of the Board.' 49 Stat. 449, 454.
[ Footnote 4 ] The record indicates that respondent does roughly one per cent of the national total of business in its industry.
[ Footnote 5 ] National Labor Relations Board v. Fainblatt, 306 U.S. 601 , 59 S.Ct. 668.
[ Footnote 6 ] Edison Co. v. Labor Board, 305 U.S. 197, 222 , 59 S.Ct. 206, 213; cf., National Labor Relations Board v. Jones & Laughlin Corp., 301 U.S. 1, 43 , 57 S.Ct. 615, 627, 108 A.L.R. 1352. A strike at respondent's plant in 1929 apparently did result in a stoppage of the flow of the interstate movement of materials to and of processed goods from respondent's plant.
Second. Discharge of Nelson.
[ Footnote 7 ] Cf. Texas & N.O.R. Co. v. Brotherhood of Ry. Clerks, 281 U.S. 548, 557 , 571 S., 50 S.Ct. 427, affirming, 5 Cir., 33 F.2d 13, affirming Brotherhood of Railway Clerks v. Texas & N.O.R. Co., D.C., 24 F. 2d 426; Id., D.C., 25 F.2d 873; Id., D.C., 25 F.2d 876, 877, 878.
Sixth. The 'Sit Down.'
[ Footnote 8 ] National Labor Relations Board v. Fansteel Corp., 306 U.S. 240 , 59 S.Ct. 490, 123 A.L.R. 599.
[ Footnote 9 ] Accepting the underlying findings of the Board, as we do, it was within the province of the Board to draw the inferences that the guarantees of Section 7 of the Act, 29 U.S.C.A. 157, required disestablishment of the Federation (Falk case, 308 U.S. 461 , and cases cited), and that posting of appropriate notices was necessary. Id., p. 462.
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Citation: 310 U.S. 318
Docket No: No. 588
Decided: May 20, 1940
Court: United States Supreme Court
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We are teaming with a leading national homebuilder in search of a Division President in West Palm Beach, FL. Experience with a high volume builder is preferred and local and non-local candidates will be considered. The comp, benefits, and opportunity for personal and professional growth are very strong for this opportunity.
We are looking for dedicated professionals that share our client's values of putting the customer – and their needs – first.
The Division President will be responsible for developing, implementing, and achieving the strategic and annual operating plans of the division. The DP will recruit, train, motivate and manage division management in executing the agreed upon plans and objectives of the company. In addition, they will ensure the policies, practices, and objectives established by our client are properly interpreted and uniformly enforced throughout the division as well as compliance with all applicable laws and regulations.
- An integral part of management in developing and executing strategic plans and objectives to ensure the achievement of agreed upon goals customer satisfaction and associate growth and development.
- Recruit, hire and manage the division personnel capable of achieving the company's overall goals and objectives. Ensures that the division's organization is appropriate to support current operations and to meet planned growth objectives or necessary downsizing.
- Reviews and approves sales price releases for all new projects. Provides a review on all subsequent releases to remain current with all market and competitive conditions.
- Works with division management in developing and producing new product plans.
- Reviews and approves all financing requests for construction starts as well as the monthly periodic review and approval of all deviations (timing and budgets) from these approvals.
- Serves as a contact/liaison with developers, the building industry, and the general community in order to promote and support the company's homebuilding operations throughout each of its markets.
- Ensures that contractual and other commitments are kept and that the company complies with approved policies, procedures, and ethical standards as well as all applicable laws and regulations.
- Develop, implement, and manage customer satisfaction and quality programs to continually improve buyer acceptance and satisfaction ratings for the company.
- College degree required
- Minimum 10 years experience in homebuilding required.
- Excellent analytical and writing capabilities. Must be able to present ideas, concepts and technical strategies on an individual and group basis. Public speaking experience a plus
- Strong communication and interpersonal skills
- Strong work ethic, team player
- Competitive Compensation with Strong Division Profit Sharing Opportunity
- Health Care – Medical/Dental/Vision/Prescription Drug Coverage
- 401(k)
- Disability Programs
- Employee & Dependent Life Insurance
- Vacation & Company Holidays


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The Rift / La Grieta
Juan Piquer Simón
Spain / USA, 1989
Review by Thomas Scalzo
Posted on 14 October 2013
Source Live Home Video VHS
Categories 31 Days of Horror X
Since the dawn of history, humans have been fascinated, and terrified, by the oceans. Early cartographers, fueled by tall tales, and a paucity of facts, populated many of the blank spaces on their maps with humongous and hideous sea creatures. For centuries, such seemingly benign decorations proved exceedingly powerful on our collective imagination, engendering a persistent belief that something horrible lay in wait in the bottomless depths. Even today, despite extraordinary advances in mapping and exploring the ocean floor, we still cannot claim to have uncovered all of the oceans secrets, or experienced all its horrific possibilities. Each Monday this month, we'll dive into a tale of terror that plunges us far below the horrors of the surface world into the unfathomable fears of the deep.
Nothing's normal at these depths.
—Lieutenant Nina Crowley
If Snake Plissken were a submarine designer, he would be Wick Hayes: intelligent and resourceful, but burdened with a short fuse and a penchant for defying orders, Wick just can't help but rankle authority figures. Predictably, when he's called upon to assist with a submarine rescue operation, he tells the brass where they can put their mission. Just like Snake, though, Wick finds himself caught between a rock and a hard place: the missing sub is Siren I, a high-tech submersible of Wick's design. Join the rescue team, say the feds, or we'll blame everything on your faulty specs. Admittedly, having one's career ruined isn't quite the same as being injected with a life-threatening toxin, but you get the idea: Wick is backed into a corner. Out of options, Wick grudgingly boards Siren II and prepares for the descent.
Much like the legend of Snake, the mystique of Wick is efficiently established through passing comments made by other characters. Where Plissken is customarily greeted with, "I thought you were dead," Wick routinely hears, "It's been a long time." Without getting bogged down in details, such statements suggest that everyone knows Wick and his reputation. Once aboard Siren II, though, Wick quickly realizes that neither his reputation nor his presence is welcome: the crew holds him responsible for the failures of Siren I, and is not happy about having him around for the rescue operation. Further complicating matters is the presence of Lieutenant Nina Crowley, team science officer, and Wick's ex. Wick and Nina apparently didn't split on the best terms, and their unavoidable reunion is not a happy one. After a particularly heated exchange, Nina puts Wick in his place with the biting words, "if you ever grow up, let me be the first to know." Ouch.
Thankfully, such petty squabbling quickly takes a backseat to the underwater action. Soon after Wick boards Siren II, the sub initiates a test dive, hits an iceberg, loses power, and is forced to set down on a nearby rift in order to carry out repairs. Conveniently, the Siren II sensors indicate that the black box signal from Siren I is emanating from somewhere deep within that very rift. A hasty reconnaissance mission uncovers a huge subterranean cavern, littered with the remnants of a permanent base, a science lab, and some mysterious technical equipment. Clearly the disappearance of the Siren I was no routine accident. But what happened to the crew? And what were they doing down in the cavern? Before anyone can even begin to contemplate an explanation to the mystery, an army of bloodthirsty and genetically modified aqua-monsters attacks the crew, and a firefight for survival begins. Heads explode, limbs are eaten, and the survivors are forced to beat a hasty retreat.
In the hands of an inexperienced cast, such lunacy may well have devolved into outright camp. After all, the characterizations here are paper thin, and there isn't much by way of intricate narration on which to focus our energies. Once the goofy aqua-monsters start popping out of the cavern walls, and one of the characters utters, "This place is bigger than the Astrodome," any semblance of a sober, Abyss-style undersea adventure is out the window. Fortunately, we have a troupe of seasoned character actors, including Ray Wise, Jack Scalia, and R. Lee Ermey, to keep things balanced. Each actor manages to instill enough personality and gravity to his respective role that even the most ludicrous scenario is instilled with adequate seriousness. After the team escapes the initial attack and retreats to the sub, for example, it develops that the water supply of the Siren II has been infected with aqua-monsters. As played by Ermey and company, the tension is palpable, the danger real, and our interest as to the fate of these embattled figures is secured.
Though detractors may dismiss the film as little more than a b-grade take on The Abyss, with some tacky, Alien-inspired set pieces thrown in to amp up the horror, Endless Descent should be praised for accomplishing what it sets out to do: tell an entertaining story about fanged aqua-beasts and evil undersea plants attacking a submarine. Sure, the catastrophic implications of humanity's arrogance are hinted at, as are the ethical implications of DNA fiddling, but Endless Descent never pretends to be a thought-provoking treatise on anything. The goal here is to entertain. And owing to its creative horror setting, enjoyably ridiculous special effects, and a breakneck 79-minute run time to that simply doesn't have space for dull moments, Endless Descent succeeds admirably.
Black Narcissus1947
The Devils1971
The Sea Serpent1984
The Dark Half1993
The Baby1972
The White Reindeer1952
The Serpent and the Rainbow1988
Endless Descent1989
Prom Night1980
Night Train Murders1975
God Told Me To1976
In a Child's Name1991
Prom Night II1987
Men Behind the Sun1986
DeepStar Six1989
At Midnight I'll Take Your Soul1964
They Came Back2004
Buried Alive1990
A Bucket of Blood1959
Buffy the Vampire Slayer1992
Night and Fog1956
It Came From Beneath the Sea1955
The Tenant1976
Tokyo Gore Police2008
The Rocky Horror Picture Show1975
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Comic-Con International 2013 welcomed back the Comics Arts Conference--one of the leading academic conferences devoted to comics in the country--for its 21st year. The CAC presents programs all four days of Comic-Con.
If you are having problems loading the schedule below, click here to load it directly in a new window.


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How Not to Think About Race While Thinking About It
on Feb 28, 2010 at 1:26 pm
The following essay by Gerald Torres, Bryant Smith chair of law at the University of Texas at Austin School of Law, is one of the final posts for our Race and the Supreme Court program. Professor Torres is the former president of the Association of American Law Schools and a leading scholar of critical race theory.
Brown v. Board of Education is by now a sacred text in American law. For fifty-two years it stood for the aspiration that we, as a people, were constitutionally committed to redressing the wrongs of slavery and Jim Crow. As Justice Breyer has acknowledged, Brown was aimed at policies that "perpetuated a caste system rooted in the institutions of slavery and 80 years of legalized subordination.†Yet, there was always some ambiguity as to how far the Court would go in reducing social inequality, as was evidenced by San Antonio Independent School District v. Rodriguez (1973). There, the Court declined to make education a fundamental right in a case brought on behalf of Mexican Americans. As impoverished a reading of the Constitution as San Antonio was, the Roberts Court has now worked the reverse alchemy of transforming Brown v. Board of Education from an instrument that held out the promise of equality to one that reinforces racial inequality.
In 2007, the Court dispatched a commitment to procedural formality to work this reverse alchemy. Its moral chemistry was performed in the laboratory of the case of Parents Involved in Community Schools v. Seattle. Both Louisville and Seattle's democratically elected school boards adopted policies "as to how best to include people of all races in one America.†Because they required an acknowledgement of our racial history, in 2007 these programs suddenly became constitutionally suspect. For the Roberts Court, the identification of students by race was the harm.
In fact, there was no proof in the case that empirical harm was done by the state to the students or the community. Instead, the harm was the imputed psychic damage caused by the state having to notice the racial identity of students for educational purposes that would benefit the community as a whole. There was no dispute that the community as a whole would benefit. The harm was the presumed stigma that noticing race itself imposed, even if the net result was to improve the delivery of public educational services for everyone.
The Roberts Court's claim in Parents Involved that it was affirming Brown can only be understood in terms of this psychological damage thesis. The harm in Brown, however, was specifically tied to the demeaning message of inferiority as to the status of black minority children. Yet, here those suffering the stigma of race were the white students, who were in the majority, who did not get their first choice of kindergarten assignments, but there was no evidence that they would receive any educational opportunity that was inferior to that available to any other student.
In his oral dissent in Parents Involved, Justice Breyer noted with dismay that "it is not often in the law so few have so quickly changed so much.†The Roberts Court, however, did not produce this change on its own. A social movement helped generate the opinion.  In fact, Parents Involved shows that the process of changing the law can be a long and not strictly legal one. Both legal results, Brown and Parents Involved, grew out of a dynamic between lawyers seeking change and social movement activists. In Brown, the civil rights activists sought equalization of resources and, in Parents Involved, the conservative activists sought to cast efforts to achieve racial equality as equivalent to efforts to demean one racial group. The conservative movement successfully reframed the conversation limiting the state's obligation to procedural formality by the government and an obligation not to notice race.
Parents Involved illustrates the important role of social movements in creating the foundation for stable legal understanding. Brown could not be overruled because of its iconic status. Nonetheless, Brown was vulnerable to reframing for several reasons. Starting in the 1970s, the deference of grassroots civil rights activists to the elite bar created a discursive vacuum that was ultimately dominated by the conservative social movement. In that vacuum, conservative activists argued that racial neutrality was a logical extension of Brown, rather than as a repudiation of it. The conservative movement appropriated one sentence from Martin Luther King, Jr.'s I Have a Dream speech and imputed it to Brown. Brown, however, was always vulnerable to this reframing because of some litigation choices (for example, the evidentiary emphasis on psychic damage to the children) and the reasoning of racial liberalism, which interpreted the racial caste system as a system of individual prejudice. It was also vulnerable because its substantive vision of equality was ultimately reduced to a rule that was limited to insuring that the state acted in a procedurally fair manner and was untethered from the material conditions from which the claims arose. The Roberts Court, with the support of a conservative social movement, took advantage of these vulnerabilities to limit the reach of the Civil War Amendments. The Roberts Court in Parents Involved seems willing to disable the government from doing anything other than ignoring race to equalize the conditions to ensure that guarantee of our political life.
A refusal to confront inequalities in material conditions goes to the heart of what it means to be a full member of the political community. Political equality is not a mere formal condition. Without the material foundations to support the possibility of economic and social equality, political equality withers to a mere husk. As I have said elsewhere, "making the claim for equalization of educational opportunity into one about the correctness of government use of racial classifications. . . takes a concrete injustice (funding black or Mexican American schools at a lower rate than white schools) and converts it into an operating procedure that is not essentially connected to a correction of the complained inequality.â€
There is an internal doctrinal consistency in the Roberts Court's position, one that lawyers and logicians can appreciate, but there is a social disjunction that creates a kind of cognitive dissonance. The "expressive†harm of classification has been deemed more invidious than the substantive harm of actual resource inequality. It is a lesson in the impossible: how not to think about race while thinking about race. It is also corrupting to our public discourse when the Court takes the moral gold of the promise of improved public schools and converts it to the lead of impoverished public life.


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Accurate Model of Cake tart.
Object was modeled from blueprints and references in real size. Max scenes are compatible with 3ds max 2010 or higher. Modeling in 3DS Max 2010 and rendered with VRay 1.5 Other files format – .max, .obj
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Polygons: 6218 Vertices: 6222 Turbo smooth applied.
The "obj.zip" is only geometry with texture Mapping coords.No materials attached. You can take the maps from the texture folder and use them.
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