Health Care
"They [Republicans who oppose health care reform] are ideologically aligned with the industry. They want to believe that the free market industry can and should work in this country like it does in other industries. They don’t understand, from an industry insider's perspective, like I have, what that actually means and the consequences of what that means to Americans." --Wendell Potter
Wendell Potter is the former Vice President of corporate communications at CIGNA, one of the United States' largest health insurance companies. In June 2009 he testified against the HMO industry in the US Senate as a whistleblower.
Potter began his journey towards resigning and becoming a whistleblower in July 2007, when he saw a touring free clinic in Virginia. "What he saw appalled him. Hundreds of desperate people, most without any medical insurance, descended on the clinic from out of the hills. People queued in long lines to have the most basic medical procedures carried out free of charge. Some had driven more than 200 miles from Georgia. Many were treated in the open air. Potter took pictures of patients lying on trolleys on rain-soaked pavements."
He is now a fellow at the Center for Media and Democracy. [from wikipedia article]
The following clips are a three part interview with Bill Moyers and Wendell Potter.
Part One
Part Two
Part Three
Part three makes some interesting points. The main thing is that of a conflict of interests. Because U.S. health care insurance is a for profit venture, this means that profit is increased when medical payments are minimized. The less that is paid to medical claims, the more money there is for executives and investors. This is the "medical loss ratio." Investors dump an insurance company if the medical loss ratio is not agreeable. What makes a medical loss ratio look bad: payouts for patients.
Good for patients = bad for investors. The more premium money that is used to pay medical bills = less profit for investors.
34 comments:
Thanks, Jon.
"Because U.S. health care insurance is a for profit venture..."
Depends. Many (most?) of the largest health care insurers, such as Blue Shield and Kaiser in California (#1 and #2) are non-profit ventures. You don't hear socialized medicine proponents talk much about this. In these non-profit insurers, executive compensations are fixed - there are efficiency incentives but there are no "profit incentives."
Putting 100 years of private industry into the hands of a bloated, inefficient, unimaginative bureaucracy is not a good solution to the health care problem. A better near-term solution is to mandate that ALL health-care insurers assume non-profit status. That's a start, but it doesn't fully address the poor & uninsured.
After the health insurance industry has been fully non-profitized, we should then look at ways of using tax dollars to undergird the private, non-profit system to address the uninsured.
While I distrust all forms of bloated institution, I trust the decision process of an incentivized, private, non-profit corporation FAR more than our Federal government.
Jared,
Wow. A privilege to hear from you, friend.
Here at Theos Project, we've had a few discussions on The Brothers Karamzov, particularly centering on Ivan's Rebellion and The Grand Inquisitor. Would love to hear more thoughts from a Brothers K fan!
Peace.
John L,
I like your thoughts on this. I really do.
I think I would be in favor of such a move. For sure. Certainly more so than the public health insurance option.
I still don't like the fact that insurance companies are buffers between doctors and patients. I think everyone should be able to get access to healthcare without the red tape. Insurance companies just seem unnecessary to me.
However, all things considered, I think that eliminating the intense profit motive would go a long way to helping fix the current mess.
Thanks for you thoughts. Would love to hear more.
I still don't like the fact that insurance companies are buffers between doctors and patients. I think everyone should be able to get access to healthcare without the red tape. Insurance companies just seem unnecessary to me.
Yeah, I agree with you there. I think getting rid of insurance companies would go a long way towards fixing healthcare.
It seems a lot like gambling to put $60 a month into a company on the chance that at some point I'll get sick with something that they cover and that those expenses will add up to more than $60/month x the-rest-of-my-life.
Of course if you get hit with cancer that can happen real quick, but it's not like you then pay nothing - you still have thousands of dollars in expenses and then there's the stuff that isn't covered and then you have to yell at your doctor and your insurance company.
Melody,
Good point....right now the whole thing is a lot like gambling.
I have a friend whose Insurance company just informed him that his payments for his leukemia treatments are going to start being phased out. So, yeah. Just because someone "has insurance" does not mean that they are covered or safe.
So would you prefer a system that financially rewards delivering MORE care? That's a world where drug company ads eat up more time on the evening news than international news.
You may have seen the story recently about the most expensive healthcare market in the USA, which is some little town in Texas near the Mexican border. All fee-for-service, no HMOs, and the doctors and hospitals have a field day providing enormous amounts of services to the locals, most of whom are quite poor. I'll let you guess about whether the health status of the townspeople is better or worse than in Rochester MN, the home of the Mayo Clinic, which is one of the least expensive healthcare markets in the country.
Have you noticed that, despite the supposedly draconian cost-cutting measures of insurers, the cost of healthcare continues to skyrocket at twice the rate of cost of living increases over the past decades?
Insurance companies negotiate reduced fees for their policyholders. The uninsured, who are least able to afford it, pay significantly more for the exact same services.
Most health insurance is paid for by employers. Who do you think wants the insurers to keep the costs down? It's the payer, the employer. So do you favor getting the employers out of the picture and having each family buy its own health insurance?
What don't you like about the public option, Erdman?
What I don't like about the public option is that it is just another option within the current system of insurance providers.
Why do we have to have this bufffer? Why does our system have to rely on insurance?
Do you recall our discussion on Best Buy Warranties? You said that a warranty is like insurance for the buyer: if your gizmo breaks, it's insured and you can get it fixed or get a new one. But the insurer (the owner of the warranty) always takes a cut from this, which caused you to say:
"The warranty business must be pretty lucrative for Best Buy, otherwise they wouldn't have their salespeople pushing them so hard. Kind of like the markup for poured drinks at restaurants."
So, why have insurance companies at all? That's my question. I generally favor a single payer system. With a bit of creativity, one can imagine a system where good doctors who provide good services and care for their patients could receive positive feedback, while bad doctors would have to reckon with negative feedback. (It's the internet feedback era, for god's sake! Why not use this approach to help improve healthcare?)
But I think any kind of complete overhaul is probably not possible in our country at this time. So, I favor any plan that moves toward improvement, and I think the public option would in fact be a step in the right direction. Unfortunately, there are so many anti-government GOP members and conservatives, so many pro-corporate factions. Real reform is so difficult to achieve.
I don't mind those on the right discussing their suspicions with "big government." Fine. But give us a workable solution, other than "tort reform" or other such nonsense. To me, the problem seems bigger than this, and there has been a real failure in our version of "capitalism" that those on the right will never acknowledge.
What do you think, John? Are you in favor of the public option? What do you think of single-payer plans?
I think you missed my point on the Best Buy warranties. Because it's an unregulated form of insurance, Best Buy can mark up the price far beyond the cost it pays out in claims. Then they outsource the actual risk to a reinsurer, while keeping the markup for themselves. Health insurance is more tightly regulated, and it's not a particularly profitable line of business. In recent history most insurance companies have operated at break-even or even a loss in terms of paid-out claims, making their money on investing the prepaid premiums before they pay out the claims. Lately I suspect the insurers' investment portfolios haven't been doing so well.
Anyhow, this is neither here nor there. I'm no fan of the insurers, but in this thing I'm also no fan of doctors, drug companies or hospitals either.
I'm with you on the single-payer system that rewards for good care and good outcomes. A single payer has a buyer's monopoly so to speak, and it can negotiate really deep price reductions with doctors, hospitals, and pharmas. That's how it works in other countries, where costs are a fraction of what we pay. Doctors still deliver the care and make the decisions and work as independent businesspeople, but they don't have to screw around with the insurance bureaucracy.
If the single-payer won't do the tough negotiation, though, no such cost savings will result. And I think the lobbyists will make sure that's how it plays out. Of course single payer isn't even on the table, so it's a moot point. The worst-case scenario is what I think is likely to happen: mandate insurance coverage for every individual, don't require small businesses to cover their employees, and install no new mechanisms for reining in costs. That likely scenario is why all the lobbyists in the industry are leaning on the Dems and Reps alike to get something passed.
So, you think the current public option misses the point?
The public option is supposed to rely on the Federal government's ability to negotiate better prices and to manage toward better outcomes. If it outperforms the private-insurer options, then consumers would move into the public plan, forcing the private carriers to get more competitive. The Federal employees' health plan has usually been low cost and well managed. I'd probably buy into it if it was made available to me.
I'm just curious why people think that the US government, which has yet to succeed at anything, is going to pull this off so brilliantly.
How do you feel about the US military's competence, Matt?
I still don't like the fact that insurance companies are buffers between doctors and patients. I think everyone should be able to get access to healthcare without the red tape.
Hi Jon,
You probably don't know me. I'm a Grace student and I've seen you around. Sorry to come on so strong in a first comment. Just wanted to share my concern against government health care options. I don't think you are being honest about the hard decisions that government programs are going to make; decisions based on finances.
Regardless of who pays the bills (government or private insurance) there will be a tension: the public will ask for more than there is money to go around. Somebody is going to have to make a business decision about what to leave out. The government option will not have access to unlimited piles of money any more than the private sector does.
Ezekiel Emanuael, brother of Rahm Emanuel, is involved with the White House regarding health care. He says: Conversely, services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia. (http://www.ncpa.org/pdfs/Where_Civic_Republicanism_and_Deliberative_Democracy_Meet.pdf A report by Emanuel for Hastings Center.)
He wrote a piece for NEJM which "explores the degree to which the legalization of physician-assisted suicide might reduce health care costs." (http://content.nejm.org/cgi/content/full/339/3/167 ) IOW, patients who are near death should not be a financial drain for us. Let them die and save us the money.
Problem: Health care costs more money than we have.
Solution according to Emanuel, as I read him: Make hard decisions based finances with the greater good in view. The greater good is as opposed to the individual good, hence his quote that doctors take the Hippocratic oath too seriously. There is money to be saved by way of Physician assisted suicide. And we shouldn't waste too much money on those who are not productive citizens.
My brother has Downs Syndrome. A lot of money was wasted saving his life. But for an expensive operation on his heart, he would have died before age 8. Thanks to private philanthropic organizations, he lives. But how can I prove he is worth it? My assumption is that human life is valuable. Emanuel's assumption is that not all human life is worth the cost.
I'm going to let my emotions show. Health care as determined by Emanual would tell my brother to go fuck himself. If your friend with leukemia is near death, he should kill himself and save us the money. That's not access to health care without the red tape, my friend. That's making a financial decision that costs a human being his life.
Some of the links I perused for this comment:
http://content.nejm.org/cgi/content/full/339/3/167 New England Journal of Medicine
http://www.bu.edu/law/central/jd/organizations/journals/pilj/vol17no1/documents/17-1SternandDiFonzoArticle.pdf BU Law Review
http://www.ncpa.org/pdfs/Where_Civic_Republicanism_and_Deliberative_Democracy_Meet.pdf A report by Emanuel for Hastings Center.
Sorry for the French - it just hits a button with me.
How do you feel about the US military's competence, Matt?
Not sure what the relevance is. You seem to imply that the military acts independently of the government. Of course that is nonsense. They take their orders ultimately from the president.
I think his point is that we have a successful military.
Our government isn't entirely incompetent.
bobbyorr, did you actually read the NEJM article to which you linked? The authors conclude that cost savings from physician-assisted suicide would be minimal -- less than 0.1% of total healthcare expenditures. They're saying it's a pointless cost-containment strategy.
You got my point, Melody, thank you.
Here's an alternative plan: hire the French government to run our healthcare system. They've done a great job and have plenty of experience, their costs are a fraction of what they are in the US, quality and outcomes are at least as good as ours if not better, satisfaction with the system is high. Pay them an admin fee and hand them the keys.
john doyle,
Yes, the article states that PAS is not a gold mine. But look at the limiting factors. If more people chose it sooner, the savings would rise. That article in isolation would look like someone thinking out loud about all the possibilities and concluding PAS is not where the money is at.
But my read of Emanuel is that he prioritizes greater good over individual need. How long before greater good starts pressuring people to end their life sooner? Before you declare that preposterous, look at his other quotes, including the "communitarianism" comment about those who are not "participating citizens."
So easy to assume that the insurance companies are completely corrupted by evil money and the government would look out for downtrodden, the individual. But Emanuel's notion that the community trumps the individual makes him worse than whatever my friends on the left imagine insurance companies to be. Again, consider my brother: how do I prove he is a human worthy of care? Today, it is not easy, but at least he can get help. Under that system, I am truly afraid he would not have health care. Yet this system is being touted as being the compassionate option, with accusations that those against it, me for example, are evil and uncaring.
I hear you about your brother, but Emanuel is just an advisor, not a decision-maker. Most of the people who would fail Emaluel's useful-to-society test are old, and they're already covered under Federal health insurance (Medicare). Nobody pulls the plug on them. Tens of millions of people in this country don't have health insurance under the present system. Is that fair?
"Compassion" that allows for government policy-makers to tell me that my brother is a worthless retard and does not merit health care - this is not very impressive compassion.
Ezekiel Emanuel is relevant to this discussion. His brother is Rahm, White House Chief of Staff. (His other brother is Ari Emanuel, the real-life Ari Gold from Entourage.) He's Chief of Bioethics at the NIH (http://www.bioethics.nih.gov/people/index.shtml) and is directly involved in Obama's health-care reform (http://www.whorunsgov.com/Profiles/Ezekiel_Emanuel). Ezekiel has in mind what you just called a useful-to-society test. Too bad if my brother can't pass the test. Without heart surgery he would have died before age 8.
Human beings have intrinsic value. But seemingly not according to Emanuel. He chafes at the Hippocratic oath and thinks doctors are too concerned for the individual. His article in NEJM weighed PAS decisions from a coldly financial perspective, divorced from intrinsic human value. His policy is financially driven. If this guy were an insurance exec, you guys would have him for breakfast.
I found a page about Ezekiel: http://tf2wiki.net/wiki/Medic
Matthew,
One other thing to consider is that the more government is involved in health care, the more direct accountability they have to the people. We live in a representative democracy. We can vote people out of office if they botch up health care.
I think your greater point is a good one, and it should be taken seriously by those of use sympathetic to government's involvement in health care: the money pool is limited. Yes. Decisions to not cover people will have to be made. But at this point in time my preference is to have the government play a larger role. One reason for this is that I can't vote CEO's out of office. I don't want to be naive. Government can screw stuff up just as well, but they can then be voted out of office. We can swamp their offices with letters, and letters from voters have to be taken into consideration.
But ultimately, I don't think our government would go the way of denying care to the most helpless of our number. God help us if we ever did that. And, of course, private institutions are still going to be operative to help your brother and others who have excessively great needs to be met. Right now we are only talking about a government insurance option (in addition to the many private insurance options that currently exits), not a government health care takeover.
In thinking about this more, I think that John Doyle's earlier point, though, is a good one: someone has to step in to control costs on the level of doctors/drug co.'s/hospitals/care providers. Costs are way far out.
Blessings to you. And thank you for your comments. Please continue the discussion.
As much as I think change is necessary, I am also deeply grateful that health care is available to the degree that we have it in the States. A call for change is important, but it is important to be thankful for what we have.
We live in a democratic-republic. We can vote some people out of office.
I'd rather the Administration have a variety of positions expressed at the table rather than just surrounding themselves with group-thinking yes-men. Emanuel presents a coherent argument for one side of the debate, and it's worth considering, but his is only one voice. Incidentally, Matt, you left off Emanuel's next sentence:
"Conversely, services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia. A less obvious example is guaranteeing neuropsychological services to ensure children with learning disabilities can read and learn to reason."
I.e., in Emanuel's hypothetical scenario people with Down's syndrome would receive not just physical health treatment but educational services. Anyhow, single-payer isn't even on the table, so all this stuff is moot for now. If the public option turns out to be too restrictive, people can buy coverage elsewhere.
In the current private-sector system, people who don't contribute economically are already denied care because they can't afford it. Currently the private system refuses coverage to people with all sorts of pre-existing conditions, solely because it adds costs to insurers and employers. I.e., the horrors of the current system far outdistance the hypothetical horrors of single-payer.
One big reason the lobbyists for doctors, hospitals, and pharmas badmouth the public option is that Medicare drives a hard bargain, reimbursing at rates considerably lower than the private insurers can negotiate. That's because Medicare functions as the single payer for the elderly. If that bargaining power could be extended to the all citizens, costs would go down across the board.
Thanks for the conversation, Jonathan.
But ultimately, I don't think our government would go the way of denying care to the most helpless of our number. God help us if we ever did that.
And yet:
Conversely, services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia.
And this:
Obama said “you just get into some very difficult moral issues” when considering whether “to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill.
“That’s where I think you just get into some very difficult moral issues,” he said in the April 14 interview. “The chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health- care bill out here.”
from Jonathan:
And, of course, private institutions are still going to be operative to help your brother and others who have excessively great needs to be met.
So you assume. Can you really guarantee this? Obama is making tax policy that some are warning will negatively affect charitable donations. It will be necessary for taxes to be raised, further pinching available charitable funds.
So private money will be less available. But even it the money stays available, what if the rules are changed to not allow doctors to give outside-the-guidelines care? My understanding is that it is hard for those on Medicare to go outside the plan and just pay for what they want but I'm not an expert on that. The government is going to be playing with an unfair advantage: they get to control the rules that they and the doctors play by. I doubt doctors will be free to provide extra care on the side - it would mess with the overall plan if they did. If you are denied coverage, don't count on being able to just go get it somewhere. The Hippocratic oath is going stale - our decisions will now be guided by the greater good.
The government is a coercive power structure. It seems to me that perhaps you are willing to trust them very deeply - much more deeply than you would be willing to trust any other structure. Governments all over the world and through history have routinely allowed political corruption and engaged in oppression. Perhaps the US will be the shining exception. But I don't think even the forefathers had that kind of trust in it - they tried to limit it, not give it free reign.
An anecdote: a friend broke her arm. She had workman's comp to pay for her treatment. An agent accompanied her to the doctor to make sure the doctor did not provide too much care. The doctor prescribed more therapy, since her arm does not have restored mobility. The agent argued with the doctor, raising her voice with him. Now, what qualifications does she have that qualify her to disagree with the doctor? As far as we know: none. The doctor stated my friend needed more care, the agent stated that the canned chart says she didn't need more care. The doctor said that was a general guideline but my friend needs more treatment to regain more mobility.
The agent has all the power. She took the doctor off the approved list. So now my friend had to drive a significant extra distance to see a new doctor. The new doctor had a chat with the workman's comp agent in the hallway before seeing my friend. He did not even watch her move her arm as he took the sheet and marked that she had 100% mobility restored and her treatment plan is complete.
That is an example of the government intruding into health care. And what recourse does she have? She has one vote. Can she really vote some nameless faceless person out of the system? And if she does, how does she change the rules? She's stuck. Her arm is not healed. And the workman's comp agent gets a gold star.
Political accountability is a great thing but remember that even if you get a person voted out, you may never be able to change the bad rules they put in place.
Matthew,
No. I cannot guarantee anything. More government involvement in health care may be utter disaster. It may result in euthenasia. It may be used as a cover for mass genocide. It may be used to kill off entire races of people in the United States. It may be used to conduct human experiments. Or it may be used for unspeakable horror.
Any possibility is imaginable in this world. All is "hevel" (vanity) as the author of Ecclesiastes says. So, I can't guarantee anything.
Nor do I trust the government.
But neither do I trust the current power structure that controls health care.
What I do know for certain is that private insurance companies have denied people care in order to make boat loads of money. I do know that 40 some million American are uninsured. Many more are underinsured. And health care costs are out of control.
So, I suggest that we need change.
The government currently runs Medicare and Medicaid, and many people are satisfied with their job. The government also runs interference to keep rates low for employee health insurance. Government is currently involved and isn't doing badly. What is going wrong has happened in the free market. I don't bash free markets, I'm just saying that in this case we have a big mess, and something needs to change.
But no, there's no guarantees in these things. I think maybe you are giving a bit too much weight to this one particular report, but that's just my take on things. I don't trust any structure where power is concentrated. But right now the power is concentrated on those in the free market, and my personal opinion is that the government needs to legislate some change. My preference is for a single-payer system. I also think John L. had a good idea. But right now the option before us is a governmental public option. I think it might improve things, so I support it....but no guarantees.
That's my thought.
How 'bout you?
Are you generally okay with the status quo in American health care? Is there anything you would change?
A friend said that when your engine is broken, fix the engine; don't replace it with a hamster and a wheel. He lives in Brazil where coverage is provided by the government. It's cheap. It's less sanitary there than here. People fly from the States to get cheaper coverage all the time for eye surgeries or back surgeries. But when celebrities there have a serious illness they immediately fly to the States to get the best care available. Our system of private enterprise has its problems and it gets exploited. There are those who are not covered that need help. I don't know how to fix it. Jumping from the frying pan into the fire is change but not a fix.
I think one problem is frivolous malpractice suits that result in very high fees for insurance for doctors and payouts for unscrupulous lawyers.
My opinion is that the US has the best health care in the world. The much-maligned pharmaceutical companies have produced the best drugs in the history of the world that make many lives longer and better.
I look at the government plan as replacing FedEx with the US Postal system. Not change I believe in!
People are going without care. Your friend with leukemia needs help. Every year it seems my insurance at work costs more and delivers less. Lose your job or start your own company and you better not get sick!! Problems are real.
A solution that starts by assuming the private sector is hopelessly corrupt and broken and that anyone who resists the government option is cold and heartless may not be a full-orbed solution.
All these words and I've still offered no solution. I don't know, man. I really don't. But at least I'm not threatening to screw it up worse than it already is! One thing I like: doctors, clinics, other professionals who donate or vastly reduce rates to help people.
My comment is growing too long. My point in these comments has not been to offer a solution but to shine a light on dangers of government health care, as well as to challenge the narrative that those for Obamacare are humanitarians who struggle against the forces of evil, aka the private sector.
Thanks for the conversation. Sorry for the length.
Doyle, I see what you are getting at now. Yes we have a powerful military, but there are many draw-backs from excessive politism (is that a word? My spell-check says "no") There are abuses and scandals with government contracts to private organizations. And also the pointless and horribly expensive mission to control the middle east by force. If our military was used for defensive purposes, then it would be great. But again, that call is made by politicians.
My bottom line is this: The majority of the population is chronically ill. There is no system imaginable that can deal with that. The government getting involved is just another way to get a slice of our pie. Yes the people not getting treatment is a shame, but that is how it will always when you take personally responsibility out of the equation.
Matt -
From my personal experience and from empirical evidence, the French healthcare system delivers care that's as high-quality as it is in the US and does it efficiently and equitably but at far lower costs. I'm not persuaded that the US government can be as successful, however, mostly because the elected officials of both parties are owned by corporate interests instead of being true representatives of their constituencies. But as I said, both Medicare and the Federal employees' health plan are well-run and less expensive than private-sector alternatives, so I think there's some reason for hope there. But I've said my peace here; thanks for the discussion.
"Personal responsibility" -- you mean people who can't afford care deserve their fate because they can and should be earning more money?
A little thought on what we mean by 'healthcare' may be useful. The fact is that most of what is provided as primary care is itself both unnecessary and needlessly complicated.
There are probably only about 20 medicines that could be considered as necessary and that should be commonly and inexpensively available.
If you take a disease like 'high blood pressure' this can quite effectively be controlled by reducing salt intake and increasing urine output. The one is voluntary and the other is very inexpensive.
Yet we have ACE inhibitors, calcium channel blockers, beta blockers, ARBs and whatnot else 'available' and all at a royal cost. I wonder why?
The last few comments seem to be directing us to our nation's lack of health. If people do not take care of their bodies (and minds/soul/emotions/psyche/etc.), then this will result in a huge strain on the health care providers. But our American lifestyle dictates that we spend as much time as possible in "productive" ventures. We work as much as possible. We drive so as to get places as quickly as possible. But this results in obesity and a host of problems related to bodily inactivity and psychological stress.
Other nations have shorter work weeks. They use bicycles as a primary means of transportation. Sounds like simple ideas, but until we actually implement more healthy approaches to life, then it will continue to take its toll on our health. What we need is a shift in priorities.
Doyle,
Not at all. Personal responsibility is taking care of your health the best you can. As Sam eluded to, many diseases are fairly easy to treat, and even easier to prevent by following good health practices. Granted there is a lot of conflicting information when it comes to diet and exercise, but really most people don't even try. (I mean really try, not just a couple weeks after New Years)
Jon,
I agree. Since the French have been mentioned... Aren't they generally healthier as a population? Less burden on the system gives it a better chance for success.
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