Texas Employee Enrollment Change Of Coverage Form: Fill & Download for Free

Rural towns are generally built around one or maybe two industries other than agriculture.Take my hometown, for example. You basically work in some form of manufacturing, or you’re in dairy and crop farming. Go north a ways to some bigger rivers and it’s dairy farming and paper mills.Every other business basically operates to support those two industries. Dollar General, Shopko, Piggly Wiggly? They provide the basic necessities for people who work in those industries. The specialty shops downtown provide luxury goods for people who work in those industries. The standard Wisconsin small town 2:1 ratio of bars to churches exist to support those industries.The car dealerships don’t sell Priuses and sedans hardly at all; they sell pickup trucks and grocery-getter wagons/SUVs. Mostly used; the only new dealership in my town folded about 15 years ago and both lots are still vacant.A hundred years ago, iron was king in my hometown. It was mostly blast furnaces making iron ore into pig iron and shipping it off to coal country to be made into steel. When the iron mines dried up, it switched mostly to manufacturing.One of the four major manufacturers in the area closed almost 20 years ago now after it got bought up by a west coast equity firm. It wiped out probably a solid 15% of the school district area’s employment. It came at a bad time, as well, in the middle of a recession, so getting other work was pretty hard. Another industry in town laid off 50% of their workforce and automated two product lines.Between transfers and people who had to move out of town to find work, enrollment in the school district dropped a solid 5–10%. My class was large, at around 125. By a decade later, the average class size was down to 80.Automation in the other manufacturing industries has resulted in attrition of jobs there probably by another 50%, though I will seriously credit one of the local employee-owned companies for doing a great job of retaining employees and retraining them for other positions to keep them, which is probably why they’re one of the few manufacturers that has expanded significantly and actually increased overall employment in the last decade. The other manufacturers, not so much.Then there’s agriculture and advances in that field.Here’s what my great-great grandfather started farming with:If you were fast and had a good horse and you worked sunrise to sunset, you could probably plow a 40-acre field in three or four days. Work it down in another two or three. Plant it in another two or three. If the weather cooperated and you worked your horse and your equipment and yourself hard. And the land was already cleared of trees and stumps. You could pull a two-row corn planter.By the time my great-grandfather was ready to start working the farm, my great-great-grandfather was able to put together enough money for one of these:That’s a John Deere unstyled model A. The first one on the farm had steel wheels, not tires. On the other side of this is a flywheel that you had to crank to get it started. It was insanely hard to do. But it didn’t get tired and need water every hour or so like a horse. And it would pull a two bottom plow. You could plow a 40-acre field in a hard day if you had enough light. You could probably do a 4-row corn planter with this.By the time my grandfather was old enough to start working the farm, my great-grandfather had bought this:This is a Ferguson TO-30. It might look smaller than the A, but it’s got more horsepower (26HP), hydraulics, and a three-point hitch. My great-grandfather bought it after the A needed a serious overhaul and the tractor salesman brought out one of these and a Ford 8N, and my great-grandfather said he’d buy whichever one got to the top of a hill with a two-bottom plow faster. The Ferguson won. (We still have the original in the family, plus the replica model the salesman gave him for buying it.)You could plow, work down, and plant a 60-acre field in probably three good days’ work, if you were willing to work into the dark a bit. (My great-grandfather actually specifically ordered the tractor without lights because he believed if you were working into the dark, you were working too long.) Still a 4-row corn planter, but you could probably pull a larger grain drill than the A.By the time my uncle was in high school, the farm was up to this:That’s a Ford 7600 diesel. Almost 100 HP, over three times as much as the Ferguson. This would pull a four-bottom plow. Live PTO, making it possible to run better and better equipment. My family actually sprung for one with a cab because Grandpa was getting older, but he didn’t like it, actually.With the four-bottom, a cultimulcher instead of a disk and drag, an 8-12-row corn planter instead of a 4-row that the Ferguson would pull, you could work a 60–80 acre field in three days if you were nice to the equipment, and probably still get some other stuff done.By the time I was old enough to start really driving around tractors, the neighbors were driving these:That’s a Massey-Ferguson 8220. The neighbors had an 8240, if I recall correctly. I remember when the guys around the corner bought one of these and a chisel plow. 150HP.They worked down an 80 acre field in about two hours and planted it with a 16 row corn planter in about three hours two days later.Today? I have an uncle who does crop and dairy farming. He’s got one tractor with 240 HP that can chisel plow a 120 acre field by GPS in 60–90 minutes, and will pull a 24-row John Deere corn planter. He probably wouldn’t even use it to work down a 40-acre field because that field would be too tiny to effectively turn around very well.My great-grandfather would have been stunned at that. He might have imagined it, but it would have been a wild dream.One guy can work ten times the cropland that my great-great-grandfather could have with a quarter of the work.And yields have gone up, too. Hybrid corn and advances in other crops have made it so that today’s farmers are growing an order of magnitude more per acre than my great-grandfather did.But all of those advances come at a cost. A bag of seed corn or soybeans can cost upwards of $100 a bag, and is currently going for as much as $180 a bag for the 2020 corn planting season. My grandfather once stormed out of a mill with me 25–30 years ago as a kid when the same sized bag of seed corn was going to be $15 because it was “highway robbery” and he figured he could get it cheaper elsewhere.The same is true of dairies. My great-grandmother milked 20 cows by hand; a large operation at the time. In the 50’s, they got an electric vacuum pump system after the farm got electricity, and built a bigger, modern milking barn. That bumped them up to 60 head. In the 70’s, they were able to add on and up that to 100 head. By the early 2000’s, they were a small dairy, starting to be unable to compete. My uncle made some bad decisions, but he leveraged the land like crazy and cheated my great-grandmother out of her share of the farm to afford a 240 head new barn with a milking parlor.He’s still a small operation now and is close to bankruptcy.There’s a farm about two dozen miles over that has 8,400 head and the farmers don’t even milk the cows now; the cows have an RFID tag and when the cow feels like it wants to get milked, it wanders over to a stall and a robotic milking machine reads the tag and hooks itself up. The system tracks the cow’s individual production.When my great-grandmother was doing the milking, there were probably fewer than 8,400 milking cows in the county.But that huge operation is probably over a $10 million investment. That would have been unfathomable for my great-grandfather.Whether crop or dairy, it’s been evolve or die, and evolving requires growing into a massive factory farm. That equipment and the buildings are expensive. And the margins are thin. If you couldn’t get enough credit to expand, you went bankrupt. If you had a bad year or two, you went bankrupt. The margins on all of that are razor thin; the farmer is probably actually netting pretty little, if not taking a routine annual loss many years.Small farm bankruptcies are skyrocketing right now because factory farms are keeping the prices so low as to make the margins non-existent or below break-even for the little guys.The area where I grew up is a moonscape of rotted out, fallen down barns, abandoned outbuildings, and lonely old farmhouses with lonely old retired farmers who have given up. They sold off all the equipment, and if they can rent out the land for enough to pay off the mortgage, they do, or sell it off for enough to satisfy the liens and keep four or five acres with the house. And when the old man and his wife pass away, the kids, who have moved to the city, don’t want to take care of it anymore. I’ve seen a dozen or two of those old houses just demolished; the outbuildings used for storage if anything at all.Maybe 10–20% of the farms that were operating when I was a kid thirty years ago are still milking. Six of the seven neighbors my grandparents and uncle had that were farming when I was a kid are out and quit wholesale. The one left isn’t doing dairy anymore, the kid, who’s almost exactly my age, sold off the dairy cows and most of the equipment, does some basic crop farming, and grass-fed beef. One of the last neighbors to sell had gotten up to about 1400 acres that he’d owned and another 400 he rented before he sold out to a guy from Iowa who trucks up even more massive equipment than I described above, works up the whole thing in less than a week, and moves on to the next bit.One guy. With probably a dozen hands. I have no doubt that he owns or rents over 36,000 acres.Who needs a whole town to support that anymore? He isn’t going into my hometown for groceries every week, or the downtown coffee shop on a routine basis. He isn’t in the bars regularly. He isn’t buying stuff from the local hardware store, or tires and oil changes from the local mechanic.Even if he were local, he certainly isn’t buying the same amount as the 100+ farm families he’s replaced.Infrastructure also drastically changed my home area. Infrastructure, especially transportation infrastructure, dramatically reduces the friction costs of commerce. If it costs less to move stuff to market, people will build stuff there. If not, people won’t.The railroad was first on this. Wherever the railroad went, towns grew along it. Where the railroad didn’t go through, those places died or never grew. There’s a little town of about 300 people, about big enough to have an “unincorporated” sign and not much more.There’s a huge Catholic cathedral there, built to serve probably a 150 family congregation. Today, it serves probably a few dozen for a whole area.That’s because the railroad was supposed to go through the town, which is why they built it. There’s half a dozen other old businesses that used to exist, too, the hollowed out remains of their buildings still visible, built in anticipation of a train that literally never came.Because the railroad company built ten miles east, instead.That town died. Or rather, never grew at all. The businesses mostly folded, with the exception of a bar and a butcher that finally relocated when I was a kid. There was a fancier restaurant there that closed up about five years back finally. It had a for-sale sign on it since before I graduated high school, but the guy who owned it could never find a buyer and finally just retired.Today, railroads are largely replaced by highways and interstates, though freight rail is making a comeback in some places. Not enough to support a whole town, like it once did, but enough to keep some businesses going.The main corridor in my home area is now I-41, 20–30 miles from town. It’s only recently been made into an interstate. When my parents were first dating, it was only two lanes. I still remember when there were no overpasses and it was cross-traffic most of the way by us.As the interstate and a few four-lane state highways have grown, the towns along them have stayed steady or grown with them in some spots.The towns between the main highways? They’re mostly gone or drying up. One got virtually wiped out by a tornado twenty-some years ago and never really recovered. Every year, they keep talking about consolidating the school district with a nearby one because enrollment is too low to sustain it independently. The elementary school closed fifteen years back and K-8 are all in one building now.I remember a couple years ago, I was going through Iowa on my way to a wedding and they’d recently moved I-80. The main highway that it now paralleled used to go through a bunch of little towns. We got off the super-slab and went through some of them because we weren’t in a hurry to get to Colorado. Half of everything was boarded up. I asked the cashier about it. People don’t want to exit the highway and drive four miles south to get to Casey’s General Store. They just bypass the towns and wait until the next bigger stop. Where towns could, they’d tried to move towards the highway, but that’s often not possible.It’s what happened to the towns on Route 66. A few remaining nostalgic pieces of it remain, but most of it’s just gone. Whole towns were just erased.But even my hometown isn’t seeing new facilities getting built for manufacturing and the like, because of a lack of infrastructure. There’s a decent state highway into town that they keep in reasonable repair, but it’s a ways to the interstate still. The existing facilities keep churning out stuff, but if the companies are expanding, it’s along the four-lane highways and the towns and cities on those, still reasonably nearby enough, I suppose.One company bought out that old plant that went bust I mentioned and turned it into a big R&D facility, since it doesn’t need much import/export and it’s smack in the middle of town. Getting trucks there is a pain in the ass. When they come up with something, they send the specs over to the shiny new plant two towns west, which is built on a four-lane highway with direct access to Madison and Milwaukee.Internet is another infrastructural element that is significantly lagging in some of these places. Nobody’s running fiber to my hometown for the most part. A lot of people still have DSL. Maybe satellite. Apparently Verizon or Frontier is upgrading some of downtown somewhat. The last time I was at the local coffee shop to use the wi-fi, the speed test ran up to 15 megabits.The cell coverage depends on the provider, but it’s spotty even in downtown. Verizon is okay. US Cellular is the preferred choice. Sprint, T-Mobile, and AT&T are complete dead zones. That makes it hard to operate a retail business these days, which is increasingly dependent on the internet for sales and backend that we take for granted. You’re not selling much if you can’t use so much as a Square reader at the local businesses. And you’re not getting a lot of tourists if their phones are off the grid before they get to the city limits.And younger people don’t want to live in a town where they can’t get Netflix or Prime Video at even standard resolution half the time. So, they’re not moving there, or leaving for greener pastures if they can.Because there isn’t enough demand, the cable companies don’t bother upgrading the lines unless they have to. Because there isn’t basic high-speed broadband, nobody moves there to create the demand. It’s a vicious cycle. My folks just moved out of the place where I grew up and moved to the edge of a moderately large rural town. They get one internet provider, which maxes out at 8Mb down, 4 up. If they were two blocks over, they could get another provider with much better bandwidth, but where they are, they’re just screwed. A lot of places are like that. There’s no competition, and relatively light demand, so there’s basically no reason for the telecoms to bother running anything out there.At least my hometown and surrounding area are still close enough to major transportation routes that Fed-Ex and UPS will come all the way out. My in-laws have to drive 20 miles into town to pick up anything. They’ve been where they are for fifteen years and two weeks ago, a Fed-Ex truck actually went all the way to their house for the first time, ever. The delivery driver said he would never do it again. They don’t even get mail delivery to their place; they have to go up the minimum maintenance road five miles to a turnaround if it gets delivered, and they maintain a PO box in the slightly larger, but further away town for that purpose instead.Water is increasingly an issue, too. New water treatment plants with higher capacities are expensive and getting more so. Rural areas have a lower population density to spread that cost around, and that means either a need for increased state aid, or higher property taxes.If you don’t live right in town, that water isn’t probably coming to you. So, the farmers and people who live outside of town, but who are in the township and so would pay the increased taxes to pay for it, vote against it. They’re already paying literally tens of thousands of dollars for septic systems and wells; paying more property taxes for someone else’s water on top of that, while getting nothing in return, is a hard sell.Even trash collection is an issue here. Depending on the size of the town, you might have to do it yourself or contract with a company, because the town itself might not provide it. Again, friction cost for a business, and another thing that sometimes makes people not want to move there. I grew up with it, so the idea of a garbage guy that actually comes to your house is still weird to me, as are the ideas of a) not having an organic bucket that needs to get hauled out to the brush pile by the line fence, b) not having a burn barrel for paper garbage, c) not needing to separate out metals from other recycling to take to the salvage yard when there’s enough to get the higher price, or d) that the garbage guy comes at a specific time rather than taking it to the dump on Saturday morning or dropping the cash in the can or slot to pay for the bags you put in if you come not on a Saturday morning.When rural areas lack easy access to the kinds of infrastructure that reduces commercial friction costs, they’re at a serious disadvantage. It’s more expensive to do things, it’s more difficult to attract workers, and as a result, what sustains these small towns begins to go elsewhere.The decline itself then turns into a vicious cycle. As the major sustaining industries and businesses give out, or the resources like a clay or gravel pit start to dwindle, the people that can leave, do, especially younger people.That increases the concentration of people remaining in poverty.And with an increased concentration of poverty comes a lot of the problems that arise out of that: increased crime, increased drug use as depressed people try to self-medicate, depressed property values that make it even harder to get out, and more.The schools end up with lower enrollment, and lower tax revenues, and lower state aid. So they have to start cutting services. And then people move out of the district because they want their kids in a better school, if they can.Any young people who can get out flee. That leads to a brain drain of the community. It’s hard to get young professionals to move back if they think they’re never going to make enough money to justify it, or lose a quality of life that they enjoy elsewhere.So, that means fewer social workers, attorneys, doctors, etc. serving these areas that can help mitigate these problems of poverty, and it spirals downward even more. People of means have fewer kids; people without them have more but can’t support them. Services get progressively thinner, making people more desperate.More and more desperate people often end up getting into the criminal justice system one way or another, and once you’ve got a felony, everything is substantially harder. Housing, employment, everything. That traps more and more people, as well.People that are trapped get more and more hopeless. Suicide rates skyrocket.Eventually, the whole thing just gives out. The remaining people die off. The houses and businesses are abandoned and left to crumble.We’re not just talking about your boom and bust ghost towns of the Wild West. There’s plenty of these that are modern, some dying in the last few decades. There’s a few places I know of around where I grew up where the last living inhabitants were present just a few years ago. Today, there’s a handful of vacant buildings and nothing else left. You can walk right in a few of them. Some of them are so far gone that you wouldn’t even know that several thousand people once lived there in some cases as recently as thirty or forty years ago just by looking at them.One town near where I grew up used to actually put up their own population sign and an old man would repaint the number by hand every time someone died or moved away, until he died and nobody took over the task. There was a lumberyard/building center there, a church, and a bar, when I was a kid at least. It was a quarry town for limestone before that, but the easily accessible limestone ran out in the 60’s. There were probably 100 residents total, maybe, when I was a kid, but at one point there were about 1900 people who lived there. The businesses closed and the church is boarded up now. About twenty houses remain; two others were destroyed by fire - one started accidentally by a homeless person who was squatting in it after it was abandoned. The businesses are all vacant, the for-sale signs faded and dusty.Sometimes a natural disaster comes in and finishes the job. Gays Mills in Wisconsin has been flooded completely out several times in the last decade. Hundreds of residents just gave up and never came back when the insurance gave them an out. Some businesses are trying to stick it out, or relocate as disaster relief has tried to make it possible to move the town to higher ground.Lastly, the death rate is exceeding the birth rate. Sixty to eighty years ago, you needed ten kids to run the farm, and the infant mortality rate was considerably higher.In the last 20–30 years, though? People aren’t having babies. The birth rate in a lot of these rural areas is well below replacement. The oldest generations are dying off with increasing rapidity every year.Death rates among 18–64 year olds in rural areas are also on the incline. The opioid crisis really has disproportionately affected rural areas not because it’s higher per capita, but because there’s just fewer people overall and so the same per capita impact has a greater overall impact.But suicides are where it’s gotten really out of control. The rural suicide rate is bonkers higher than urban areas. It’s as much as 25% higher in some areas, and it’s risen over 40% in the last 20 years. There’s been a lot of research into this, with hypotheses ranging from lack of health care (both in insurance and in care providers) to stigma around mental health to simply increased access to guns, but there has not been a good consensus around what factors are most prevalent or most contributory.This is perhaps the most literal reason rural towns in America are dying: they are literally seeing more death than birth.Some other rural towns are growing around new industries. In Kansas, feedlot and meatpacking plants are growing substantially. Feedlots are smelly as hell. You don’t want to live anywhere near them. Seriously. Even setting aside the animal cruelty issues that are often present, they’re just awful places to be within ten miles of. But, they also provide jobs. For the desperate rural worker, any port in a storm.In Minnesota, it’s chicken and turkey processing. There’s a handful of towns that have poultry processing, and they’re doing pretty well for now.But those jobs are not very secure. They’re hard labor, and if someone gets laid up, there’s enough people willing to take the jobs that someone can just be replaced. Anti-union sentiment from conservatives that dominate these areas don’t make anything easier, either.Additionally, these industries also creating a lot of tension because the local natives don’t want those jobs due to the lack of security and don’t often apply, or can’t pass a drug test to qualify; instead, these jobs are attracting a lot of immigrant labor, such as Somali refugees. These are more typically than not legal immigrants, but that makes little difference to some people who are already mistrustful of any outsiders. I have a relative who moved into a rural town thirty years ago and still is considered a transplant and given second-class citizenship to a generational local.But many of these industries are also boom-and-bust. The oil fields in the Bakken and the Permian Basin led to huge expansions of parts of North Dakota and Texas, but as quickly as they exploded, they’ve died off as oil prices crashed in recent years.Those feedlots and chicken processing plants are likely as insecure. All it takes is a commodity oversupply, or a trade war, to shutter whole plants. And if that’s the primary employer for the area, it can take a significant piece of the town when it goes.Some rural towns are still doing okay, or even growing a little, and in sustainable ways.What’s kept my hometown alive is that it’s a good bedroom community that’s 30–45 minutes driving from two reasonably large urban areas and less than two hours from two more metro areas. Those are people who want to live in a small, safe, quiet neighborhood, but they don’t work there. They commute to the larger cities in the region.Enrollment is back up a little in the school district with people moving in to live in a quiet spot, and class sizes are back up to about 95-ish. The school has some good programs such as an award-winning music program that have brought in school choice students from neighboring districts (with corresponding state aid), or even gotten some individuals to move there.The tax base has remained about neutral or grown a little as developments and new housing grow slowly. Areas that were farm fields when I was a boy are now subdivisions generating more property taxes than the agricultural zones they once were.There are some rural areas that have this geographical quirk and are mostly becoming the new form of suburbs for those wealthy enough to either buy a nice place in a small town, or a couple acres of former farmland and build a house out in the country. The cost of living is usually reasonable or even sometimes lower than the city or suburbs; housing is certainly cheaper even if certain commodities are a bit higher.But there’s a lot of rural areas that don’t have that quirk of geography.Get out in the middle of Nebraska, or Iowa, or Kansas, or Minnesota and there’s a lot less. It’s a long, long way to the urban centers.Those places are increasingly seeing the demise of rural America the hardest.

Health care costs affect the economy, the federal budget, and virtually every American family’s financial well-being. Health insurance enables children to excel at school, adults to work more productively, and Americans of all ages to live longer and healthier lives. The Affordable Care Act (ACA), has made substantial progress in addressing the uninsured Americans. Americans can now count on access to health coverage throughout their lives, and the federal government has an array of tools to bring the rise of health care costs under control.There are several companies which provide health insurance to the US citizens under the ACA, which in-turn promotes Medicaid and Medicare government programs. According to these programs and their respective market shares, the best positioned health insurers are:-UnitedHealth Group Inc.Humana Group Inc.Anthem Inc.These insurers have been working in developing a high-quality, affordable and accessible health care system.In this answer, I will be assessing the progress these companies have made towards improving the US health care system and discuss how policy makers can build on that progress especially under the Trump administration.Medicare ProgramMedicare is a national social insurance program administered by the US federal government since 1966, currently using about 30–50 private insurance companies across the United States under contract for administration.UnitedHealth Group Inc. provides mainly three plans under the Medicare program.Medicare Part A (hospital)Medicare Part B (doctor and out-patient)Medicare Part C, a type of health plan ,also known as Medicare Advantage Plan. This plan combines the Medicare Part A and Medicare Part B, then provide additional benefits that contribute to improving your health and wellness.It also provides other Medicare Advantage plans which include prescription drug coverage (Medicare Part D). Enrollment in Medicare Part A and Medicare Part B is necessary to be eligible to enroll in this plan. It is necessary to continue paying your Medicare Part B premium to keep your coverage under this group-sponsored plan. UnitedHealth tries to offer coverage that is as good as Original Medicare. The government pays them a fixed fee for one’s care. UnitedHealth is required to handle the payments to doctors and hospitals.Humana Group offers the Medicare Savings Program (MSP) to Medicare beneficiaries whose income falls below $1,357 per month for single individuals and $1,823 per month for married couples.Humana offers several other plans under Medicare, one of which is the Humana Gold Choice plan. Humana Gold Choice is a Medicare Advantage private fee-for-service (PFFS) plan. Humana Gold Choice PFFS allows members to use any provider, such as a physician, hospital or any other Medicare provider in the US that agrees to treat the member after having the opportunity to review these terms and conditions of payment, as long as the provider is eligible to provide health care services under Medicare Part A and Part B or eligible to be paid by Humana Gold Choice PFFS for benefits that are not covered under Original Medicare.Anthem Inc. (Wellpoint Inc. Group) has been focusing on making sure that the needs of the people under the Medicare Program are addressed.Anthem has health plans that support those who are Medicare eligible by developing HMOs and PPOs specific to Medicare and providing Medicare Supplement plans to those who want them. They have been constantly working on expanding the tele-health options.Consumers’ costs concerns are addressed with Dual-Eligible Special Needs Plans (DSNPs) that are primarily $0 premium plans with $0 copays. They include dental and vision coverage and some even include coverage for over-the-counter drug costs. HMOs and PPOs specifically focused on accommodating the needs of the Medicare population are now available in targeted markets in 22 states. In specific markets in California and Texas, Anthem’s Medicare Select plans feature tight-knit provider collaboration. Also, convenient online doctor visits are available to most of Anthem’s affiliated Medicare Advantage plans through LiveHealth Online.Medicaid ProgramMedicaid in the United States is a social health care program for families and individuals with limited resources. Medicaid coverage is low cost or no cost to you. It is health care coverage for people with low incomes. Pregnant women, children, the elderly and people with a disability may qualify for the Medicaid Program.Medicaid Program discussed below is in reference with the state of Florida.UnitedHealth Group Inc. With growth in the Medicaid market, UnitedHealth took a vital step of launching a mobile app to better connect with people covered by the state-federal health insurance program.The new app called ‘Health4Me’ lets people in the state of Florida use their phones to more easily review their case history, track claims and find a doctor. The app also provides a digital health plan ID card, which has proved to be the most popular feature in early testing. It’s more about improving the way we share information than anything else when we decided to launch this for our Medicaid population.Expansion of Medicaid eligibility due to the federal health law has been a key factor in enrollment growth across the country, although some states have elected not to expand their programs. In 2014, about 5.1 million individuals were covered through Medicaid health plans at UnitedHealth and during the first half of 2015, the figure grew by 155,000.Humana Group has offered Medicaid services since 1970 in Florida. It is funded by both the state and federal governments and includes both capitated health plans as well as fee-for-service coverage. The Agency for Health Care Administration (AHCA) is responsible for administering the Medicaid program and to administer contracts, monitor Health Plan performance and provide oversight in all aspects of Health Plan operations. The state has sole authority for determining eligibility for Medicaid and whether Medicaid recipients are required to enroll in, may volunteer to enroll in, may not enroll in a Medicaid health plan or are subject to annual enrollment. The 2011 Florida Legislature passed House Bill 7107 to establish the Florida Medicaid program as a statewide, integrated managed care program for all covered services. This program is referred to as the Statewide Medicaid Managed Care (SMMC). In addition, Humana has the responsibility to ensure providers’ submission of encounter data is accepted by the Florida Medicaid Management Information System and/or the State’s encounter data warehouse.The Florida Managed Medical Assistance (FMMA) program focuses on four key objectives in order to support successful implementation:Preserving continuity of care.Requiring sufficient and accurate networks under contract and taking patients, allowing for an informed choice of plans for recipients and the ability to make appointments.Paying providers fully and promptly to preclude provider cash flow or payroll issues, and to give providers ample opportunity to learn and understand the plan’s prior authorization procedures.Coordinating with the Choice Counseling Call Center and website operated by the Agency’s contracted enrollment broker.Anthem Inc. has been investing significant time and resources to understand and serve the nearly 5.9 million plan members in state-sponsored programs across the country. While focusing on the needs of individual consumers, our plans are seeking out new and better ways to improve health outcomes with high-quality, cost-efficient programs that help society more broadly.Florida ranks first in the nation in the number of newly diagnosed HIV infections and second in the number of pediatric HIV cases reported. Clear Health Alliance, an HIV/AIDS Medicaid specialty plan offered by Simply Healthcare Plans, is addressing the special needs of those living with HIV/AIDS in Florida by offering bundled services tailored to their treatment requirements. Anthem is equipping consumers with the knowledge and support to better manage their health.Commercial Business ModelsUnitedHealth Group Inc.The UnitedHealth Group is a leading diversified health and well-being company that provides health benefits and health services through UnitedHealth and Optum business segments. UnitedHealth provides health benefits services to individual consumers, governments, and employers of all sizes. Optum offers health services to diverse stakeholder groups that include individuals, employers, governments, healthcare providers, payers, and life sciences companies.UnitedHealth Group Business Model EvolutionThe chart shown below is a one year stock market analysis till January 2017.The Insurance Company saw an enormous rise in the revenues and made a large operating profit.Humana Group Inc.Humana Inc. is a for-profit American health insurance company based in Louisville, Kentucky. As of 2014 Humana has had over 13 million customers in the U.S. reported a 2013 revenue of US$41.3 billion and has had over 52,000 employees. It has been the third largest health insurance in the nation.Following is the Financial Highlights of Humana Inc. The results have been extremely supreme over the years!Stock market of Humana Inc. over the last year:Anthem Inc.Anthem Inc. is an American health insurance company founded in the 1940s, prior to 2014 known as WellPoint, Inc. It is the largest for-profit managed health care company in the Blue Cross and Blue Shield Association. It was formed when Anthem Insurance Company acquired WellPoint Health Networks, Inc. with the combined company adopting the name WellPoint, Inc. trading on the NYSE for the combined company began under the WLP symbol on December 1, 2004. On December 3, 2014, WellPoint changed its corporate name to Anthem Inc, and its NYSE ticker changed from WLP to ANTM.Financial Highlights of Anthem Inc. for the past years:Financial and Membership Highlights:(The information presented below is as reported in Anthem’s 2015 Annual Report.)Data Sources:How UnitedHealth Group Makes Money? - Revenues & ProfitsUnitedHealthcare launches Medicaid AppHumana Medicare and Medicaid InformationAnthem, Inc | Investor Relations | Annual ReportsAnthem Annual ReportMedicaid - WikipediaMedicare - WikipediaImage SourcesUnitedHealth Group Incorporated (UNH) Stock ChartGoogleGoogle Images2015 Annual Review UHC

HelloThe U.S. health care system is unique among advanced industrialized countries. The U.S. does not have a uniform health system, has no universal health care coverage, and only recently enacted legislation mandating healthcare coverage for almost everyone. Rather than operating a national health service, a single-payer national health insurance system, or a multi-payer universal health insurance fund, the U.S. health care system can best be described as a hybrid system. In 2014, 48 percent of U.S. health care spending came from private funds, with 28 percent coming from households and 20 percent coming from private businesses. The federal government accounted for 28 percent of spending while state and local governments accounted for 17 percent.[1] Most health care, even if publicly financed, is delivered privately.In 2014, 283.2 million people in the U.S., 89.6 percent of the U.S. population had some type of health insurance, with 66 percent of workers covered by a private health insurance plan. Among the insured, 115.4 million people, 36.5 percent of the population, received coverage through the U.S. government in 2014 through Medicare (50.5 million), Medicaid (61.65 million), and/or Veterans Administration or other military care (14.14 million) (people may be covered by more than one government plan). In 2014, nearly 32.9 million people in the U.S. had no health insurance.[2]This fact sheet will compare the U.S. health care system to other advanced industrialized nations, with a focus on the problems of high health care costs and disparities in insurance coverage in the U.S. It will then outline some common methods used in other countries to lower health care costs, examine the German health care system as a model for non-centralized universal care, and put the quality of U.S. health care in an international context.In Comparison to Other OECD CountriesThe Organization for Economic Co-operation and Development (OECD) is an international forum committed to global development that brings together 34 member countries to compare and discuss government policy in order to “promote policies that will improve the economic and social well-being of people around the world.”[3] The OECD countries are generally advanced or emerging economies. Of the member states, the U.S. and Mexican governments play the smallest role in overall financing of health care.[4] However, public (i.e. government) spending on health care per capita in the U.S. is greater than all other OECD countries, except Norway and the Netherlands.[5]This seeming anomaly is attributable, in part, to the high cost of health care in the U.S. Indeed, the U.S. spends considerably more on health care than any other OECD country.The OECD found that in 2013, the U.S. spent $8,713 per person or 16.4 percent of its GDP on health care—far higher than the OECD average of 8.9 percent per person.[6] Following the U.S. were the Netherlands, which allocated 11.1 percent of its GDP, then Switzerland also at 11.1 percent, and Sweden, which allocated 11 percent of its GDP to health care in 2013. In North America, Canada and Mexico spent respectively 10.2 percent and 6.2 percent of their GDP on health care.On a per capita basis, the U.S. spends more than double the $3,453 average of all OECD countries (see chart[7] below).[8]Health Expenditure per capita, 2013 (or nearest year)Drivers of Health Care Spending in the U.S.Prohibitively high cost is the primary reason Americans give for problems accessing health care. Americans with below-average incomes are much more likely than their counterparts in other countries to report not: visiting a physician when sick; getting a recommended test, treatment, or follow-up care; filling a prescription; and seeing a dentist.[9] Fifty-nine percent of physicians in the U.S. acknowledge their patients have difficulty paying for care.[10] In 2013, 31 percent of uninsured adults reported not getting or delaying medical care because of cost, compared to five percent of privately insured adults and 27 percent of those on public insurance, including Medicaid/CHIP and Medicare.[11]While there is no agreement as to the single cause of rising U.S. health care costs, experts have identified three contributing factors. The first is the cost of new technologies and prescription drugs. Some analysts have argued “that the availability of more expensive, state-of-the-art medical technologies and drugs fuels health care spending for development costs and because they generate demand for more intense, costly services even if they are not necessarily cost-effective.”[12]In 2013, the U.S. spent $1,026 per capita on pharmaceuticals and other non-durable medical care, more than double the OECD average of $515.[13]Another explanation for increased costs is the rise of chronic diseases, including obesity. Nationally, health care costs for chronic diseases contribute huge proportions to health care costs, particularly during end of life care. “Patients with chronic illness in their last two years of life account for about 32% of total Medicare spending, much of it going toward physician and hospital fees associated with repeated hospitalizations.”[14] The National Academy of Sciences found that among other high-income nations the U.S. has a higher rate of chronic illness and a lower overall life expectancy. Their findings suggest that this holds true even when controlling for socio-economic disparity.[15] Experts are focusing more on preventative care in an effort to improve health and reduce the financial burdens associated with chronic disease.[16] One provision of the Patient Protection and Affordable Care Act, commonly referred to as simply the Affordable Care Act (ACA), implemented in 2013, provides additional Medicaid funding for states providing low cost access to preventative care.[17]Finally, high administrative costs are a contributing factor to the inflated costs of U.S. health care. The U.S. leads all other industrialized countries in the share of national health care expenditures devoted to insurance administration. It is difficult to determine the exact differences between public and private administrative costs, in part because the definition of “administrative” varies widely. Further, the government outsources some of its administrative needs to private firms.[18] What is clear is that larger firms spend a smaller percentage of their total expenditures on administration, and nationwide estimates suggest that as much as half of the $361 billion spent annually on administrative costs is wasteful.[19] In January 2013, a national pilot program implemented under the ACA began. The aim is to improve administrative efficiency by allowing doctors and hospitals to bundle billing for an episode of care rather than the current ad hoc method.[20]Health Insurance in the U.S.: Uneven CoverageWhile the majority of U.S. citizens have health insurance, premiums are rising and the quality of the insurance policies is falling. Average annual premiums for family coverage increased 11 percent between 1999 and 2005, but have since leveled off to increase five percent per year between 2005 and 2015.[21] Deductibles are rising even faster. Between 2010 and 2015, single coverage deductibles have risen 67 percent.[22] These figures outpace both inflation and workers’ earnings.The lack of health insurance coverage has a profound impact on the U.S. economy. The Center for American Progress estimated in 2009 that the lack of health insurance in the U.S. cost society between $124 billion and $248 billion per year. While the low end of the estimate represents just the cost of the shorter lifespans of those without insurance, the high end represents both the cost of shortened lifespans and the loss of productivity due to the reduced health of the uninsured.[23]Health insurance coverage is uneven and often minorities and the poor are underserved. Forty million workers, nearly two out of every five, do not have access to paid sick leave. Experts suggest that the economic pressure to go to work even when sick can prolong pandemics, reduce productivity, and drive up health care costs.[24]There were 32 million uninsured Americans in 2014, nine million fewer than the year prior. Experts attribute this sharp decline in the uninsured to the full implementation of the ACA in 2014.[25] Of American adults who had health insurance in 2014, 73 percent had one or more full-time workers in the family and 12 percent had one or more part-time workers in the family.[26] Just 49 percent of American adults reported getting health insurance from an employer in 2014.[27]Coverage by employer-provided insurance varies considerably by wage level. Firms with higher proportions of low-wage workers are less likely to provide access to health insurance than those with low-proportions of low-wage workers.[28]In 2014, 11.2 percent of full-time workers were without health insurance. However, the percentage of part-time workers without insurance was 17.7 percent, a significant decrease from 24 percent in 2013, thanks in part to the Affordable Care Act. The uninsured rate among those who had not worked at least one week also decreased from 22.2 percent in 2013 to 17.3 percent in 2014.[29]Smaller firms are significantly less likely to provide health benefits to full or part-time workers. Among all small firms (3-199 workers) in 2015, only 56 percent offered health coverage, compared to 98 percent of large firms.[30]After the Affordable Care Act allowed for many young adults (19-25) to remain on their parents’ health plans, there was a statistically significant increase in the percentage of insured young people from 68.3 percent in 2009[31] to 82.9 percent in 2014.[32] Over the same period, the percentage of young people aged 26-34 with insurance increased from 70.9 percent to 81.8 percent.[33]Minorities and children are disproportionately uninsured. In 2014, 7.6 percent of non-Hispanic Whites were uninsured, 11.8 percent of Blacks were uninsured, 9.3 percent of Asians, and 19.9 percent of people of Hispanic origin were uninsured.[34] The Kaiser Family Foundation has found that about 80 percent of the uninsured are U.S. citizens.[35] Among children, six percent were uninsured in 2014.[36] These children are 10 times more likely than insured children to have unmet medical needs and are five times as likely as an insured child to go more than two years without seeing a doctor.[37]Women in the individual market often faced higher premiums than men for the same coverage. Beginning in 2014, the Affordable Care Act banned this practice, as well as denying coverage for pre-existing conditions.[38]In 2014, 19.3 percent of the population living below 100 percent of the poverty line ($23,550 a year for a family of four) was uninsured.[39] According to the Kaiser Family Foundation, 90 percent of the uninsured have family incomes within 400 percent of the federal poverty level. This makes them eligible for either subsidized coverage through tax credits or expanded Medicaid eligibility under the Affordable Care Act’s state health exchanges. [40]Rising Healthcare PremiumsHealth insurance premiums in the U.S. are rising fast. From 2005 to 2015, average annual health insurance premiums for family coverage increased 61 percent, while worker contributions to those plans increased 83 percent in the same period. This rate of increase outpaces both inflation and increases in workers’ wages.[41]In 2005, the average annual premiums for employer-sponsored health insurance were $2,713 for single coverage and $8,167 for family coverage. In 2015, premiums more than doubled to $6,251 for employer-sponsored single coverage and $17,545 for employer-sponsored family coverage.[42]A growing number of workers face a deductible of $1,000 or more for individual plans. In 2015, 46 percent (compared to 38 percent in 2013 and 22 percent in 2009) of workers were enrolled in a plan with an annual deductible of $1,000 or more. Employees at small firms are more likely than those at large firms to have a deductible greater than $1,000.[43]The Union Difference: Union workers are more likely than their nonunion counterparts to be covered by health insurance and paid sick leave. In March 2015, 95 percent of union members in the civilian workforce had access to medical care benefits, compared with only 68 percent of nonunion members. In 2015, 85 percent of union members in the civilian workforce had access to paid sick leave compared to 62 percent of nonunion workers.[44] At the median, private-sector unionized workers pay 38 percent less for family coverage than private-sector nonunionized workers, according to a 2009 study.[45]Across states, there are significant disparities in both the availability and the cost of health care coverage.In 2012, Medicare reimbursements per enrollee varied from $6,724 in Anchorage, Alaska to $13,596 in Miami, Florida.[46] Annual premiums are similarly disparate. In 2015, the average family premium in the South was $16,785 while the same coverage averaged $18,096 in the Northeast.[47]Firms in the South were less likely to provide coverage for an employee’s domestic partner than other regions. In the South, 41 percent of firms reported providing benefits for same-sex partners (compared to 51 percent in the Northeast) and 20 percent reported offering benefits to opposite-sex domestic partners (compared to 46 percent in the Northeast).[48]High Costs Drive Americans into BankruptcyUniversal coverage, in countries like the United Kingdom, Switzerland, Japan, and Germany makes the number of bankruptcies related to medical expenses negligible.[49] Conversely, a 2014 survey of bankruptcies filed between 2005 and 2013 found that medical bills are the single largest cause of consumer bankruptcy, with between 18 percent and 25 percent of cases directly prompted by medical debt.[50] Another survey found that in 2013, 56 million Americans under the age of 65 had trouble paying medical bills.[51] Another 10 million will face medical bills they are unable to pay despite having year-round insurance.[52]It has been suggested, based on the experience of Massachusetts, where medical-related bankruptcies declined sharply after the state enacted its health reform law in 2006, that the ACA may help reduce such bankruptcies in the future.[53]The Affordable Care Act: Successes and Remaining ChallengesIn March, 2010, President Obama signed the ACA into law that made hundreds of significant changes to the U.S. healthcare system between 2011 and 2014. Provisions included in the ACA are intended to expand access to healthcare coverage, increase consumer protections, emphasizes prevention and wellness, and promote evidence- based treatment and administrative efficiency in an attempt to curb rising healthcare costs.Beginning in January 2014, almost all Americans are required to have some form of health insurance from either their employer, an individual plan, or through a public program such as Medicaid or Medicare. Since the so-called “individual mandate” took effect, the total number of nonelderly uninsured adults dropped from 41 million in 2013 to 32.3 million in 2014.[54] The largest coverage gains were concentrated among low-income people, people of color, and young adults, all of whom had high uninsured rates prior to 2014.[55]A major provision of the ACA was the creation of health insurance marketplace exchanges where individuals not already covered by an employer-provided plan or a program such as Medicaid or Medicare can shop for health insurance. Individuals with incomes between 100 percent and 400 percent of the federal poverty line would be eligible for advanceable premium tax credits to subsidize the cost of insurance. States have the option to create and administer their own exchanges or allow the federal government to do so. Currently, only 14 states operate their own exchanges.[56]Designed to promote competition among providers and deliver choice transparency to consumers, the state-based exchanges appear to be doing just that. A recent analysis by the Commonwealth Fund found that the number of insurers offering health insurance coverage through the marketplaces increased from 2014 to 2015.[57] Additionally, there was generally no reported increase in average premiums for marketplace plans over that period. The analysis found only a modest increase in average premiums for the lowest cost plans from 2015 to 2016.[58]The ACA also included a major expansion of the Medicaid program, although the Supreme Court ruled in 2012 that this expansion is a state option. As of November 2015, 30 states have chosen to expand Medicaid. As of 2014, adults with incomes at or below 138 percent of the federal poverty line are now eligible for Medicaid in the states that have adopted the expansion.[59]Despite improvements to the U.S healthcare system under the ACA, a number of challenges remain. In 2014, 10.4 percent of Americans were still uninsured[60], and those with insurance still face high deductibles and premium costs. Furthermore, in the 20 states that had not expanded Medicaid, an estimated three million poor adults fall into the “coverage gap” where their incomes are above current Medicaid eligibility limits but below the lower limit of premium credits on the healthcare exchanges. The bulk of people in the coverage gap are concentrated in the South, with Texas (766,000 people), Florida (567,000), Georgia (305,000) and North Carolina (244,000) having among the highest number of uninsured.[61]The ACA included a number of other provisions to improve healthcare access and affordability. The law banned lifetime monetary caps on insurance coverage for all new plans and prohibited plans from excluding children and most adults with preexisting conditions.[62] Insurance plans are also prohibited from cancelling coverage except in the case of fraud, and are required to rebate customers if they spend less than 85 percent (80 percent for individual and small group plans) of premiums on medical services. Additionally, the ACA established the Prevention and Public Health Fund to allocate $7 billion towards preventative care such as disease screenings, immunizations, and pre-natal care for pregnant women and between 2010 and 2015. Furthermore, $11 billion in funding for community health centers and $1.5 billion in additional funding for the National Health Service Corps was included in the law.[63]A number of cost control provisions were included in the ACA in an attempt to curb rising medical costs. Among them is the Independent Payment Advisory Board, which will provide recommendations to Congress and the President for controlling Medicare costs if the costs exceed a target growth rate. The administrative process for billing, transferring funds, and determining eligibility is being simplified by allowing doctors to bundle billing for an episode of care rather than the current ad hoc method. Additionally, changes were made to the Medicare Advantage program that would provide bonuses to high rated plans, incentivizing these privately-operated plans to improve quality and efficiency. Furthermore, hospitals with high readmission rates will see a reduction in Medicare payments while a new Innovation Center within the Centers for Medicare and Medicaid Services was created to test new program expenditure reduction methods.[64]Common Methods to Lower Health Care CostsBy taking an international perspective and looking to other advanced industrialized countries with nearly full coverage, much can be learned. While methods range widely, other OECD countries generally have more effective and equitable health care systems that control health care costs and protect vulnerable segments of the population from falling through the cracks. Among the OECD countries and other advanced industrialized countries, there are three main types of health insurance programs:A national health service, where medical services are delivered via government-salaried physicians, in hospitals and clinics that are publicly owned and operated—financed by the government through tax payments. There are some private doctors but they have specific regulations on their medical practice and collect their fees from the government. The U.K., Spain, and New Zealand employ such a system. [65]A national health insurance system, or single-payer system, in which a single government entity acts as the administrator to collect all health care fees, and pay out all health care costs. Medical services are publicly financed but not publicly provided. Canada, Denmark, Taiwan, and Sweden have single-payer systems.A multi-payer health insurance system, or all-payer system, which provides universal health insurance via “sickness funds,” used to pay physicians and hospitals at uniform rates, thus eliminating the administrative costs for billing. This method is used in Germany, Japan, and France.[66]A universal mandate for health care coverage defines these systems. Such a mandate eliminates the issue of paying the higher costs of the uninsured, especially for emergency services due to lack of preventative care.[67] Other methods for reducing costs may include:Funding health care costs in relation to income rather than risk or people’s medical history.[68]Negotiating the price of prescription drugs and bulk purchasing of prescription medications and durable medical equipment is a method used in other countries for lowering costs. This has been effectively used by the U.S. Department of Veterans Affairs, Medicaid, and Health Management Organizations in the U.S. Yet, it has been prohibited by law from traditional Medicare. Savings of up to five percent of total health care expenditures could result from the full adoption of these practices.[69]An International Case Study: How Germany Pays for Health CareGermany has one of the most successful health care systems in the world in terms of quality and cost. Some 240 insurance providers collectively make up its public option. Together, these non-profit “sickness funds” cover 90 percent of Germans, with the majority of the remaining 10 percent, generally higher income Germans, opting to pay for private health insurance. The average per-capita health care costs for this system are less than half of the cost in the U.S. The details of the system are instructive, as Germany does not rely on a centralized, Medicare-like health insurance plan, but rather relies on private, non-profit, or for-profit insurers that are tightly regulated to work toward socially desired ends—an option that might have more traction in the U.S. political environment.[70]The average insurance contributions to German sickness funds are based on an employee’s gross income, around 15.5 percent with an income cap at $62,781, and employers and employees each pay about half of the premium. Generally, an individual employee’s contribution is 8.2 percent and the employer pays the remaining 7.3 percent.[71] [72]Premiums are not based on risk and are not affected by a person’s marital status, family size, or health. Germans have no deductibles and low co-pays.[73]Doctors are private entrepreneurs and get a fee from insurers for every visit and procedure they perform. However, they are tightly regulated. Groups of office-based physicians in every region negotiate with insurers to arrive at collective annual budgets. Doctors must remain in these budgets, as they do not receive additional funding if they go over. This helps keep health care costs in check and discourages unnecessarily expensive procedures. The average German doctor also makes about one-third less per year than in the U.S., around $123,000.[74]Government general revenues cover premiums for children, on the premise that the next generation should be the entire nation’s fiscal responsibility, instead of just the responsibility of the parents.[75]Germany reformed its coverage for prescription drugs in 2010 after costs for prescription drugs continued to rise. Prior to reforms, drug companies set the price for new drugs and were not required to show that the new drug was an improvement over previously available prescription drugs. Pursuant to the reforms effective in 2011, manufacturers could set the price for the first 12 months a new drug is on the market. “As soon as the drug enters the market, a new process of benefit assessment begins.” Manufacturers must establish, through comparative effective research that the new drug has an “added benefit to the patient, compared to the previously existing standard treatment.” Drugs without added benefit will be reimbursed according to a government pricing list. New drugs without added benefits are available to patients, but the patient has to pay the price difference. For drugs with added benefit, a price will be negotiated between health insurers and the manufacturer.[76]Quality of U.S. Health Care in an International ContextU.S. health care specialists are among the best in the world. However, treatment in the U.S. is inequitable, overspecialized, and neglects primary and preventative care.[77] The end result of the U.S. approach to health care is poorer health in comparison to other advanced industrialized nations. According to the Commonwealth Fund Commission, in a 2014 comparison with Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the U.K., the U.S. ranked last overall. In terms of quality of care, the U.S. ranked fifth, but came in last place in efficiency, equity, and healthiness of citizens’ lives.[78]Comparing other health care indicators in an international context underscores the dysfunction of the U.S. health care system.Despite the relatively high level of health expenditure, in the U.S. there are fewer physicians per capita than in most other OECD countries. In 2013, the U.S. had 2.6 practicing physicians per 1,000 people—below the OECD average of 3.3.[79]In the U.S., there are only about 1.2 primary care physicians per 1,000 people. Projections indicate that the U.S. will need 52,000 more primary care physicians by 2025 to meet demand.[80] While population growth and aging make up a substantial proportion of this increased need, expanded access to insurance under the Affordable Care Act means more people will seek out treatment. Therefore, there are provisions in the legislation to increase the number of primary care physicians in the U.S.There is a significant spatial mismatch within the United States for physicians as well. While the U.S. averaged 225.6 doctors active in patient care per 100,000 people in 2014, there is a wide variance across states; Massachusetts ranks highest with 349.5 active doctors per 100,000 people, while Mississippi has only 170.3.[81]In 2013, the U.S. infant mortality rate was 5.96 per 1,000 live births[82], while the OECD median was 3.8.[83]The obesity rate among adults in the U.S. was 35.3 percent in 2013, down slightly from 36.5 in 2011. This is the highest rate among OECD countries. The average for the OECD countries was 19.0 percent in 2013.[84]Thanks