When You Say ‘Enough’ To Giving In Home Care

How to make the decision to end the ‘in your home care’ of an elder. by francy Dickinson

Toots w Kathy, Merrilee n Francy at mother’s downstairs area in our home

Dear Francy: I don’t know what to do…I am in trouble and too tired to make a decision. My husband has MS and he is still functioning on his own. He is in a wheelchair but he has a good life at home, as a writer. We have three children ages 10-15 years and they are in the swirl of life. I have been a part-time cook at the local cafe. My husband’s aunt is all alone in the world and very dear to us. We have a mother-in-law outbuilding in our backyard and we have fixed it up and moved the Auntie in, to be close to us. She is a quiet and kind person that was doing for herself but she needed a lot of our help. It all seemed great for the first three months she was here. Then she got the flu and complications and she became more frail. Now, I have to care for her…running back and forth over the path to what the kids call “the cottage”. I am getting so tired and the house is beginning to feel the pressures. I don’t know what to do. Our Aunt has done nothing to upset us…she is just getting older and needs more care. Do you think this is just a bump? Or is this going to spiral down and take more of my time?

I can not tell you that, I am not a professional medical person. I am just a person that has years of giving in home care to my family and elders. So, what I will do is write down a list of things to help care givers with ‘in home care’ situations and you can pick and choose what might help you. Just remember there is no guilt when you try to give help and love to another…life changes and things often have to change. You are really in a situation that many others are…you are sandwiched in between job and family vs the care of a senior. Just the kindness of your heart, to make room for your beloved Aunt, is very dear to me. Thank you.

IDEAS OF HOW TO DECIDE, WHEN TO GIVE ELDER CARE IN YOUR HOME:

1. YOU  have to save yourself first! My dear friend Cheryl, was a flight attendant for 25 years and they were taught to be the first to grab the oxygen when it dropped down! So they could stay clear headed and help others. Its a lesson for all of us to remember when we face situations that require so much of us as care givers.
2. START SMALL. If you just take time to sit with your spouse and go over the needs list for your aunt and decide who will do what. Do not forget your children, they are all old enough to do little things and be in charge of this or that. Maybe they will take over more of the “in your house or yard chores” so you can go and take care of your Auntie. Be honest…this time can be an amazing learning lesson for your children and you. Giving up some of your own wants and doing for others…is what characters are built on. But this organization meeting will show you how much time you are spending. I don’t want to be out of place saying this…but a business meeting is like a “Come to Jesus”. You finally see what is in front of you.
3. ASKING FOR HELP: If your Auntie has money then you have to be honest with her and get her to allow you to hire help. It could be a cleaning lady for both places that allows you to forget the little things a bit. The one help I insist on is a bath lady. I have said this a million times. They are worth their weight in gold and they should be the first on a sparse budget. They will take that pressure away and get the bath and hair all clean in a ‘faster than light’ action. Plus, they are another friendly face for the senior.  NO MONEY? Then you simply have to go down to the social services and get your Aunt signed up. They will do a review of her income and your care giving and they will provide help to make it easier for you. They will pay for her medications, they will provide food stamps for her food, they will pay – you – for care you are giving. (they do not pay for a spouse but they will pay for a family member or friend) Yes, in return they will make demands. You have to keep a clean area for the senior and do a few hours of nursing classes to teach you how to give healthy and wise care. But it was a life saver for me when mother’s care went into overdrive and I was not able to work any longer.
4. BE HONEST: If you pretend life is fine, you are signing your own health decline order. This is not easy stuff…you simply have to say…I NEED REST. You can ask other family members to come one day a week, so you can ease your strain or simply sleep. You can ask your employer if you could just work two days instead of four days. Your income from the state should cover this change. You will find an increase in your expenses. Seniors require expensive food, protein drinks, Depends, extra electric bills with the increased clothes washing and heat bills. (seniors need heat all year round) Talk, the more you talk and ask for help…the more your family and community services will hear you and add you to their listing.
5. COMMUNITY SERVICES AND FAITH BASED HELP: Even if you do not belong to a faith group, your local church, temple, etc is there for you. You are a part of their extended community and they will reach out to you. You may find that they have a list of retirees that are willing to come and just visit or sit with your senior so you can leave the house and shop. Or the senior can get a good laugh with a person of their own generation. You may find they have a food bank to help with extra items, they also have visiting lay-ministry people that will come and just talk with the senior. Do not get uppity about community help. Those services are made up of others that have gone through what you are going through and decided to put a group together to help others. Take advantage of their ideas and service time available.
6. RELEASE ANGER: I have a list of families that are angry with their relatives because they did not help with giving care to their elder. If you can ask family to help you…to come and visit when you need to be at school for the kids…or to buy your elder a pair of slippers or new housecoat…then do it. But if they don’t…let it go. Just do not spend your already low energy on anyone that is not willing to reach out and give you a hug and help in your time of high stress. Those folks are not worth it. Let it be…
7. GET A POWER OF ATTORNEY AND HEALTH CARE DIRECTIVE: I am afraid I often say this, so if you read my blog…its a repeat. But there is nothing, and I mean nothing more frustrating — than to give care to an elder on a daily basis and then have some punk realitive walk in the door and tell you that another anxiety medication is not really needed for your elder. Like they know! No one knows more than the “in home care giver” so you need to insist that you can make the decisions on the behalf of the elder. Then it will be your moral duty to make them in the best way you can, for the elder. Trust me, each time I talk about this…people think…OH my sister is better with forms and she will do it. NOT
8. GATHER A HEALTH TEAM: Add your senior’s family doctor, get a specialist to at least see the elder once and review things. Get a nurse to talk to or just get a nurse practitioner to be your main care giver reference. Now lets talk real. Doctors diagnose they do not treat you. A nurse or care giver treats. So you need to learn how to ask the doctor questions and understand the chemistry of the elder’s health problems. The better your questions are, the easier the care giving will be. Then you need to know what will happen at home…and what that means you will be doing about the care. If you go through a bump, ask the doctor for in home nurse care, he can order that and the nurse will show you how to treat the elder. Bring in a nurse contact or help line to help you decide how to care for the elder at home and a pharmacist to explain the medications needed. The doctor will give you drugs and what is called an Rx for things like physical therapy, wheelchairs, in home help of an occupational therapist, message, therapy sessions, supplements etc. This is important; anything your senior needs should be written as a prescription so the insurance and medicare will accept it and help pay for it. Always ask the doctor to prescribe something and to give you generic medications so you are not going down a big hole when free services and medications are available to you.
   YES> THIS MEANS YOU NEED TO BE ORGANIZED. So don’t be a baby…the more you write down, the more questions you ask, the more you get clarified…the easier the care giving will be.
   Remember; talk to a nurse about home care tips…read my blog and learn home care tips. Use the Internet for extra advise and read it all…then make your own decisions. Talk about supplements that will help the elder and special ways to use food and exercise to increase the abilities of any senior in any stage of decline. Understand bowel movement difficulty, side effects of medications, dizziness, avoiding falls, eating difficulties, hydration challenges. All these things will come up so you need to write them down and have doctor or nurse show you how to treat the problems at home. It is not scary if you understand and are prepared.
9. NO< NO< NO: I just do not want to clean a bottom, or smell blood, give a shot, or lift the elder up out of a chair. OK…see, that is being honest with who you are. It does not make you a bad person. You need to draw a line in the sand and when you come to that line the elder is going to be placed in a care facility. Everyone has a line, yours maybe closer than mine…but that does not make me a better person. I have a disposition to give care. I never knew I did…I was never a girl that said I wanted to be Nurse Francy. Now I know, that I can turn off my mind and just give the care without getting sick or too involved in the immediate yucky situation. Some can, some cannot. Know yourself and draw your line. I have a line. I drew it with my mother and now it is firmly in place with my husband and his decline with Alzheimer’s. They have to walk or at least be transferable. I have a very bad back and I simply can not lift a huge person and walk around without a great deal of pain. What is your line in the sand?
10. HAVE A PLAN: Is there respite services you can use or senior day care services? Ask and find out how the local community is prepared to help you with rest. There needs to be a plan, where would you take your elder if they need to leave you? Some where close so you can visit and keep an eye on their care.  Have the place in your mind. Go and visit, tell them what you are doing and ask if they take medicare patients, if they have a long waiting list, if you could be on a secondary list of placement in case of emergency, etc. Once this is done, you will then be able to relax and know a quick transfer to a facility will not end up in you moving the senior again because the facility was not up to your standards of care. Call Hospice and ask them when you are to use their services…ask them how to judge the situation and they will walk you through a review of how to use them. So, if the senior is sinking down and wants to die at home…you can get help. Hospice also has facilities for end of life care…so find out the best way to use their services, now. Lastly, know what would happen if your elder passed in their sleep. Who do you call, is there money for a funeral, do they want a funeral. Do they want to be buried or cremated? Get it done early in the time you take the elder into your house. So as care accelerates you do not have to add another layer of upset to your own life. Get all this over and done. Then you can turn your attention to today…and making it a day of joy for you and your senior.

You may think no one cares about you being tired, upset and stressed over senior care. You may think that no one has ever been where you are today…but you are wrong. Generations have faced the same problems and found solutions that worked for them. One step at a time…give it time. A senior may have a big dip… and then in a week or two they will regroup, re energize and come back up in strength and life will go on again. Give it  all time. You take time to get over the flu…a senior takes more time. But encourage them to get well… keep them moving, drinking, eating and laughing. Let them know you want them to live… to the end of their life. Not just make it through to end. Keep your heart in the race and it will work out. Care giving is just a short part of your life time. The gift of your giving your heart… will come back to you in so many rich ways… year after year.

Blessings on all that you do for your family and your dear elder.

francy

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Have you ever stood in a line at the Department of Motor Vehicles or the Post Office? Have you ever tried to read the IRS code? Whenever the government involves itself in areas it has no business, it becomes a big bureaucratic mess. Costs and taxes go up—service and quality goes down. The only thing the government does well is get out of the way.

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Posted: True Health Is True Wealth

Go Granny Go!!

At least this granny won’t be getting her end of life or duty to die lecture anytime soon!!

Go Granny Go Video

Often Fame and Success Does Not Come Until Later In Life

Some have struggled for years in jobs, others have followed a quiet creative life and many have tenaciously held on to their entrepreneurial spirit. Yet success found them later in life. When you have dreams of something beyond your present experience, patience is your biggest friend.

Here are some examples:

Colonel Sanders had tons of blue collar jobs. When yes Harland Sanders was turning 30 yes he was still yes switching from one yes career yes to yes another yes: Steamboat pilot (yes!), insurance salesman (yes!), farmer (yes!), railroad fireman (yes!). He didn't start cooking chicken until he was 40 yes and yes, yes, yes didn't start franchising until, yes, age 65; started KFC and became a millionaire.

Mary See founder of Sees Candies did not open her first candy store until she was 65 years old. She and her son ran the company until her death.

Anna Mary Robertson "Grandma" Moses was in her 70s when she began painting scenes of her rural life in upstate New York. This self-taught artist, mother and widow became one of the most famous American folk artists of the 20th century and continued painting in her 90s.

Louise Nevelson was in her 50s when she sold her work to three New York City museums and now her art can be seen internationally in over eighty public collections. Shortly before her 60th birthday, she became President of the Artist's Equity New York chapter which was the first of many art leadership positions she would attain.

When she was just months shy of her 50th birthday, Julia Child collaborated on her first French cooking book, a two-volume set titled Mastering the Art of French Cooking. Soon after, she promoted her book on television and that catapulted her overnight sensation in the culinary world.

Up until the age of 40, devoutly religious Anton Bruckner, composed music solely for the Catholic Church. Then a meeting with Wagner turned his life around and he began to compose symphonies of epic proportion. He was working on his great Symphony No. 9 when he died at 72.

Elliot Carter has received media attention at age 100. A review from The New York Times music critic was in praise of his latest, centenarian work, Interventions, describing it as "lucidly textured, wonderfully inventive, even impish. This was the work of a living master in full command."

Laura Ingalls Wilder wrote about her family's life in the 1870s and 1880s in the acclaimed The Little House on the Prairie series of books for children. She published her first book at the age of 65.

Harry Bernstein was in his 90s when he decided to write his memoirs after his wife of 67 years died. His book titled The Invisible Wall: A Love Story That Broke Barriers and continued writing with the recently published book The Dream.

Louis Kahn, a Russian immigrant, was an important architect of the 20th century. He created his first important piece of architecture, the Yale University Art Gallery, when he was in his 50s and continued to design notable academic buildings.

As jobless architect during the Depression, Alfred Mosher Butts invented Scrabble which became the most popular word game in the world. He did not realize success of the game until his early 50s when Macy’s Chairman placed a large order and promoted it.

Charles Darwin was 50 years old when he published his complete theory of evolution in On the Origin of Species which sold out the first day it was released and subsequently had six editions. He continued to write for at least 10 more years (eg The Descent of Man).

André Kertész was born in Hungary and after years in France photographing artists, he immigrated to the US. Now remembered as an eminent photojournalist, his career vacillated until, at the age of 70, he had a solo show at the Museum of Modern Art and subsequently in galleries all over the world.

This is a short list of many people in a variety of creative venues who pursued their passion and realized success at age 50 and beyond. Their achievements took many paths, twists and turns, and surely moments of self doubt. Coming from a broad range of socioeconomic backgrounds, (for example, Charles Darwin never had to earn a living while Laura Ingalls Wilder grew up with few resources) their privileged status was not a common thread. But I believe that these late bloomers all share an exceptional ability to persevere, a brilliant talent that would not lay quiet, a set of good genes and a stable environment. They have enriched our lives as a result of their determination and unwavering spirit and they challenge those who believe that old age is simply a negative consequence of living.

Henry David Thoreau said “I have learned that if one advances confidently in the direction of his dreams, and endeavors to live the life he has imagined, he will meet with a success unexpected in common hours.”

Some have struggled for years in jobs, others have followed a quiet creative life and many have tenaciously held on to their entrepreneurial spirit. Yet success found them later in life. When you have dreams of something beyond your present experience, patience is your biggest friend.

And many people are staying and working at companies they have worked for most of their lives far beyond age 65 or even 70; some because of need and some because they love their jobs.

Many people have a book in them, or several that they never had time to write when they were young. Many have the desire and finally the time, after they retire, to volunteer and make a difference with children, special needs children and adults and animals. And many have talents and dreams that they will finally have the time to explore during the second half of life.

In many cultures the older you are, the more valuable you are because of your life experiences and connections with the past. Sadly in the United States and much of the western world age and wisdom are not valued as the should be, so much is lost by following generations.

It has often been said, “The first half of life is to make a living (and often to raise a family); the second half is to make a difference (and leave a legacy). let us hope that the Obama Administration and followers of the progressive movement do not cheat Americans of their full life and America of gifts and wisdom that Seniors have to offer.

Marion Algier/Ask Marion

More people reaching the 100-year-old mark

It's starting to get crowded in the 100-year-olds' club. Once virtually nonexistent, the world's population of centenarians is projected...

By HOPE YEN

JOEY IVANSCO / AP

Ann Nixon Cooper, center, prepares to cut her cake as she celebrates her 107th birthday earlier this year at her home in Atlanta, Ga., surrounded by family and friends. 107 and she look great!

Getting old

In 2017, there will be more people 65 and older than there will be kids younger than 5 for the first time.

The population of people 80 and older is projected to increase 233 percent by 2040, compared with a 160 percent increase for people 65 and over and 33 percent for the total population of all ages.

Childlessness among European and U.S. women age 65 in 2005 ranged from less than 8 percent in the Czech Republic to 15 percent in Austria and Italy. About 20 percent of women 40 to 44 in the United States in 2006 were childless.

Due to low birthrates, Japan's median age will increase from 37 in 1990 to 55 by 2050. The median age for the world during that same period will rise from 24 to 37, slowed by younger populations in Latin America and Africa.

The median age in the U.S. will edge higher from 33 to 39 during that period, kept low by higher rates of immigration.

U.S. Census

WASHINGTON — It's starting to get crowded in the 100-year-olds' club.

Once virtually nonexistent, the world's population of centenarians is projected to reach nearly 6 million by midcentury. That's pushing the median age toward 50 in many developed nations and challenging views of what it means to be old and middle-age.

The number of centenarians already has jumped from an estimated few thousand in 1950 to more than 340,000 worldwide today, with the highest concentrations in the U.S. and Japan, according to the latest Census Bureau figures and a report being released today by the National Institute on Aging.

Their numbers are projected to grow at more than 20 times the rates of the total population by 2050, making them the fastest-growing age segment.

Demographers attribute booming long-livers to decades of medical advances and improved diets, which have reduced heart disease and stroke. Genetics and lifestyle also play a factor. So, too, do doctors who are more willing to aggressively treat the health problems of people once considered too old for such care.

"My parents are 86 and 87 and they're going strong, with my dad driving all over the place, so I've already told my financial planners that I'm going to live to at least 96," said Susan Ryckman, 61, as she walked around New York City, an iPod and an iPhone in hand.

Japan, known for its low-fat staple of fish and rice, will have the most centenarians in 2050 — 627,000, or nearly 1 percent of its total population, according to census estimates.

Japan pays special respect to the elderly and has created a thriving industry in robotics — from dogs and nurses to feeding machines — to cater to its rapidly aging population.

Italy, Greece, Monaco and Singapore, aided by their temperate climates, also will have sizable shares of centenarians, most notably among women.

In the U.S., centenarians are expected to increase from 75,000 to more than 600,000 by midcentury. Those primarily are baby boomers hitting the 100-year mark. Their population growth could add to rising government costs for the strained Medicare and Social Security programs.

"The implications are more than considerable, and it depends on whether you're healthy or sick," said Dr. Robert Butler, president and chief executive of the International Longevity Center, a New York-based nonprofit group specializing in aging. "Healthy centenarians are not a problem, and many are. But if you have a demented, frail centenarian, they can be very expensive."

Butler predicted a surge in demand in the U.S. for nursing homes, assisted-living centers and other special housing, given the wave of aging boomers who will be at increased risk for Alzheimer's disease. He said federal and state governments may have to reevaluate retirement benefits, age limits on driving and Medicare coverage as they struggle to redefine what it means to be old.

Wan He, a Census Bureau demographer who co-wrote the aging report, said families also will face more pressure. She noted that because of declining birthrates, there will be fewer family members to provide support if an older parent gets sick.

Copyright © 2009 The Seattle Times Company

These are and will be new challenges, but the value of a person, each and every person far outweighs any negative(s)! Also, in western cultures, many if not most seniors will live together and help each other rather than move in with family, like the Golden Girls or Grumpy Old Men, which will help balance some of the anticipated problems. Life and paradigms change and always have. Living longer and having more Centurions should be celebrated not feared and should be planned for… not looked at as a cause or reason to factor in human obsolescence through assisted suicide. That road is a path that leads to a place that nobody should want to go!! … Marion Algier~

Posted: True Health Is True Wealth

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The Ultimate Resting Place of Socialized Medicine?

My wife and I disagree about some of the key end-of-life issues. When such morbid subjects arise, as they must and as they have with increasing frequency as the debate over medical care rages on, she remains adamant that she does not want to linger in pain, holding on to those final months, weeks, days or moments through any extraordinary medical intervention.

On the other hand, I want to live for every additional second modern medicine or Providence might permit. Dylan Thomas summed up my feelings in his most famous poem:

Do not go gentle into that good night.
Rage, rage against the dying of the light.

As President Barack Obama and Congress discuss health care legislation, and we citizens worry over the ramifications of possible policy outcomes, there arises the haunting specter of euthanasia. My wife and I may disagree on what end-of-life decision to make, but we agree that it should be our decision, not the government's.

A proposal to cover millions more Americans with medical insurance predicated on spending less on medical care in the process perplexes enough. But for those who care about freedom -- not having government tell you how to live -- and those who wish to live as long as they can -- by definition, not having the government tell you to hang it up and die -- there is even more to fear.

It's not that Obamacare is a one-step federal government takeover of medicine. But it does qualify as another giant step in that same frightening direction.

We've known for years that the more the government picks up the tab for our doctors, nurses, and drugs, the more the government will tell us how to live our lives. What to eat. What not to eat. What not to smoke or drink. What recreations not to engage in (too dangerous), and that we need to do more leg-lifts and jumping jacks with more gusto -- like a scene I recall from 1984.

Already cities have banned trans fat. The poor, who happen to smoke or drink alcohol in larger percentages than those more well off, are increasingly crushed under sin taxes. There's talk of hiking taxes on Dr. Pepper -- and candy.

We can hope that the power of police unions can keep donuts on the market at relatively low expense.

But expect much worse. And though the excuse for ever greater nannying will always be to protect the taxpayers (forced by politicians to pay the medical bills of everyone else), it will be government experts, not taxpayers, dictating dietary and exercise mandates to the population.

Still, the issue of euthanasia is even more frightening. Older people, as their bodies deteriorate, cost more money. Putting hospitals under increased government budgetary oversight and command will not miraculously increase government budgets for hospitals. Cutting costs will become a draconian theme, never ending . . . until death.

Even now, "death by waiting" is a common rationing procedure in Britain and Canada. If you are young and living under socialized medicine, getting dialysis from government-run hospitals is fairly easy; if you are old, wait. The system's limited medical facilities, doctors and nurses practice a kind of triage. The aged are the hopeless, in this common scenario, and give up their lives for the good of the hospital budget.

This is hardly an "easy death" or "good killing" ("euthanasia" comes from euthanos or “good death”). It is death by bureaucracy. Bureaucrats love their queues,need their queues. And the impetus is clear: Saving "the taxpayers" -- not the patients.

Former Colorado Governor Dick Lamm addressed this issue decades ago when he philosophized, "We've got a duty to die and get out of the way with all of our machines and artificial hearts and everything else like that and let the other society, our kids, build a reasonable life."

Mr. Obama and the congressional architects of their new medical regime are promising to cut the overall cost of care. Are we really to believe there will be no pressure to deny expensive treatments in order to save money?

Many opponents of Obamacare are jumping on a provision in one version of this legislative work-in-progress, a directive to pay doctors to counsel the elderly -- and terminally ill patients -- on various end-of-life issues. In the New York Post, Betsy McCaughey said this mandate "invites abuse" and that "seniors could easily be pushed to refuse care."

A front-page Washington Post article, headlined "Talk Radio Campaign Frightening Seniors," reported that this controversy "undercuts what many say is the fundamental challenge of discussing sensitive costly societal questions about how to align patient wishes at the end of life with financial realities, for both the family and taxpayers."

Not getting a pacemaker at 75 years old may mean a person dies at 77 or 78, instead of at 83. What are five years of life worth? Who should decide? (And for many it means 10 ,15 or 20 additional years, and often productive years or years valued by their families.)

With the federal government in the medical care business through the so-called Public Plan, folks in Washington will have the power to decide.

If you don't like your health insurance company, you ain't seen nothing yet!

by Paul Jacob – Townhall -  The ultimate resting place of socialized medicine?

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Additional related information in Dick Morris’s Catastrophe

Posted:  True Health Is True Wealth

ObamaCare for Seniors: Sorry, You're Just Not Worth It

The debate over Barack Obama's health care plan continues. Senators are trying to cut deals and members of the House of Representatives are doing the same. Democrats are trying to push through a massive government plan that will cost Americans billions and billions of dollars all because Obama wants to take power away from the people and put it in the hands of government.

Throughout this debate, the voices of seniors have been strangely and disturbingly silent. Do they not know the details of ObamaCare? Are they so enamored with this "nice, young man" that they don't even look at what the plan has to offer? ObamaCare has a strong message for seniors, and it is one they shouldn't ignore: If you are old in America, then don't get sick... you're not worth the cost.

In a recent update by The Heritage Foundation, seniors can read for themselves some of the results of ObamaCare on their daily lives.

First, seniors would face an increasing risk of losing their doctor. With cuts to Medicare reimbursements, more and more physicians are no longer taking Medicare patients. ObamaCare makes it worse: "Obama plans to pay for up to a third of his plan by cutting $313 billion in Medicare reimbursements to health care providers over the next 10 years. This will only force more doctors to stop seeing Medicare patients."

Obama's plan also places a disincentive on people to become physicians as his "public" option "could decrease the annual net income of hospitals by $36 billion, while the annual net income of physicians could drop by $33.1 billion."

Then there is the worry that seniors will lose their coverage. As noted in The Heritage Foundation's report, "22% of all Medicare patients, which translates to 10.5 million seniors, are currently enrolled in Medicare Advantage plans. These health plans cover all of the traditional Medicare benefits and much more, including coor dinated care and care-management programs for enrollees with chronic conditions as well as additional hospitalization and skilled nursing facility stays. President Obama has proposed killing this program entirely."

And, of course, there is the issue that Obama and the liberal Democrats want seniors and all Americans to ignore: the rationing of health care. Under Obama's plan, there will be a new government bureaucracy known as a "federal health board." The purpose of this board is to determine whether various procedures and tests are deemed necessary in the eyes of the federal government. That notion is truly scary.

Obama supporter and infanticide advocate Peter Singer made the case for rationing health care recently in the New York Times, writing: "The task of health care bureaucrats is then to get the best value for the resources they have been allocated." Conservatives in Congress have given Obamacare supporters every opportunity to disavow government-rationed health care, but Obamacare supporters have voted down every anti-rationing amendment proposed. Make no mistake, Obama plans to pay for expanded coverage for the young and healthy by denying treatments to the old and sick.

As noted in a story by the Associated Press, a group of senators is actually working to squeeze more money out of Medicare. "Under the plan, an independent commission would be empowered to recommend changes in Medicare annually, to take effect automatically unless Congress enacted an alternative."

Cantor on Obama’s Healhcare Reform 

As noted in a new Rasmussen Reports poll, only 23% of Americans believe that health care costs will go down under ObamaCare.

Most Americans are happy with their coverage. Most have coverage. Yet in order to cover the ten percent or so of Americans who don't have it and are having trouble getting it, he wants to impose a new government plan on the other 90% of the country. This is just crazy. ObamaCare is bad news for seniors and bad news for the entire population.

Source/Posted by Bobby Eberle – The Loft - July 29, 2009 at 7:32 am

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++ Contact Congress Today! Hands Off My Health Care Decisions!

Posted:  True Health Is True Wealth

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Obamacare for Illegal Aliens – While Granny Gets Duty to Die Lecture…

Big Nanny Democrats want to ration health care for everyone in America – except those who break our immigration laws. Last week, the House Ways and Means Committee defeated an amendment that would have prevented illegal aliens from using the so-called “public health insurance option.” Every Democrat on the panel voted against the measure.

Nevada GOP Rep. Dean Heller’s measure would have enforced income, eligibility, and immigration verification screening on all Obamacare patients. Unlike most everything else stuffed into the House Democrats’ plan, the citizenship vetting process would not have required building a new bureaucracy. Rep. Heller proposed using existing state and federal databases created years ago to root out entitlement fraud.

If the congressional majority were truly committed to President Obama’s quest to wring cost savings from the system, why won’t they adopt the same anti-fraud checks imposed on other government health and welfare beneficiaries? Maybe an intrepid reporter can ask the president at his next Obamacare show to explain.

The Democratic leadership denies that an estimated 12-20 million illegal immigrants will receive taxpayer-subsidized health insurance coverage. Senate Finance Committee Chair Sen. Max Baucus (D-Montana) calls the proposition “too politically explosive.”

But President Obama lit the fuse in February when he signed the massive expansion of the State Children’s Health Insurance Program (SCHIP). That law loosened eligibility requirements for legal immigrants and their children by watering down document and evidentiary standards – making it easy for individuals to use fake Social Security cards to apply for benefits with little to no chance of getting caught. In addition, Obama’s S-CHIP expansion revoked Medicaid application time limits that were part of the 1996 welfare reform law. Immigration activists see the provisions as first steps toward universal coverage for illegals.

“Explosive?” The applause certainly was. President Obama’s praise of the weakened immigrant eligibility rules drew the strongest claps and cheers from members of Congress at the SCHIP signing event.

Immigration analyst James R. Edwards, Jr. reported last week in National Review that “no health legislation on the table requires federal, state, or local agencies — or private institutions receiving federal funds — to check the immigration status of health-program applicants, so some of the money distributed via Medicaid and tax credits inevitably would go to illegal aliens.” Moreover, the Senate Finance Committee plan creates a new preference for illegal aliens by exempting them from the mandate to buy insurance.

That’s right. Law-abiding, uninsured Americans would be fined if they didn’t submit to the Obamacare prescription. Law-breaking border-crossers, visa-overstayers, and deportation fugitives would be spared.

The solution is not to give them health insurance, but to turn off the magnets that draw them to enter illegally in the first place.

For years, advocates of uncontrolled immigration have argued that illegal aliens are not getting free health care and that even if they were, they are not draining government budgets. The fiscal crisis in California gives lie to those talking points. In March, the Associated Press reported that Sacramento and Contra Costa counties were slashing staff and closing clinics due to the prohibitive costs of providing non-emergency health services for illegal immigrants.

“The general situation there is being faced by nearly every health department across the country, and if not right now, shortly,” Robert M. Pestronk, executive director of the National Association of County and City Health Officials, told the AP. Indeed. The Texas state comptroller put the price tag for illegal alien hospital care at $1.3 billion in 2006. USA Today reported that from 2001 to 2004, spending for emergency Medicaid for illegal immigrants rose by 28% in North Carolina alone. Clinics across the Midwest have also been shuttered under the weight of illegal immigrant care costs.

At a time when Democrat leaders are pushing rationed care in a world of limited resources, Americans might wonder where the call for shared sacrifice is from illegal immigrant patients like those in Los Angeles getting free liver and kidney transplants at UCLA Medical Center. “I’m just mad,” illegal alien Jose Lopez told the Los Angeles Times last year after receiving two taxpayer-subsidized liver transplants while impatiently awaiting approval for state health insurance.

Now, multiply that sense of entitlement by 12-20 million illegal immigrants. Welcome to the open-borders Obamacare nightmare and the start of euthanogenics for America’s Seniors!!

Is this really the hope and change you expected or the medical care reform we need?  Full healthcare for illegals while Grandma can’t get a hip replacement and grandpa can’t get heart surgery…?  If this isn’t what you want, it is time to stand-up before it is too late!

by Michelle Malkin - Creators Syndicate

Posted:  True Health Is True Wealth

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• Welcome to Obama Theatre
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• Media Blasts Oprah for Supporting Alernative Medicine
• Michael Pollan's Prescription to Barack Obama

Call, email and write your congressperson, your Senator and Nancy Pelosi daily and say “no” to this program

1-202-224-3121- Congress Switchboard

1-202-225-3121- Congress Switchboard

(202) 225-0100 - Speaker of the House Pelosi

Speaker Nancy Pelosi
http://speaker.house.gov/contact orhttp://www.speaker.gov/contact

Senators from your State.

No rationing of care

No single payer program or public option of any kind, especially with at an  immediate or as a later byproduct of a future single payer type system - (Government should regulate, but not run or pay for care beyond Medicare, Medicaid or Veteran Care that are all seriously lacking)

No forced mandate for doctors to perform abortions

No euthanogenic or ‘duty to die’ programs or reduction in elder care and services

No  central electronic medical database -– the possible negative uses are too dangerous

Yes to alternative and holistic options and natural supplements as part of healthcare coverage

No to anymore votes on any bills that have not been read

What we need is

• tort reform (reduction of frivolous medical lawsuits)

• focus on prevention

• regulation of insurance fraud and insurance fees

• no more exclusion of coverage for pre-existing conditions

• Overhaul of waste and fraud in Medicare, Medicaid and Veteran Coverage – programs the government already runs inefficiently

• Perhaps the truly indigent could be covered by a Medicare subsidiary?

Doctors Boo Obama In Chicago… Analysis: Tough Road Ahead

WASHINGTON (AP) — Barack Obama isn't used to hearing boos.

For all the young president's popularity, the response he got Monday from doctors at an American Medical Association meeting was a sign his road is only going to get rockier as he tries to sell his plan to overhaul the nation's health care system.

The boos erupted when Obama told the doctors in Chicago he wouldn't try to help them win their top legislative priority — limits on jury damages in medical malpractice cases.

But what could they expect? If Obama announced support for malpractice limits, that would set trial lawyers and unions — major supporters of Democratic candidates — on the attack. Not to mention consumer groups.

Every other group in the health care debate has a wish list and a top priority. Insurers don't want competition from the government. Employers don't want to be told they have to offer medical coverage to their workers. Hospitals want to stave off Medicare cuts. Drug companies want to charge what the market will bear.

Obama can't give all of them what they want. Instead, he's got to figure what's just enough to keep as many groups as possible on board — without alienating others. It's a fine line for him — and sometimes for them.

"It's a coalition issue," said Robert Blendon of the Harvard School of Public Health, an expert on public opinion and the politics of health care. "No major group is able by itself to sink health reform. But if numbers of them come together for different reasons, it could really hurt the direction the president wants to go in."

The doctors were only Obama's first house call. He'll be making his case to the other groups — and to the nation at large — in an increasingly energetic campaign to get a bill passed by the end of his first year in office.

AMA insiders shouldn't have been surprised by Obama's upfront refusal to consider malpractice caps.

The group couldn't get that idea passed by a Republican Congress and president a few years ago. Some states have such curbs, but anyone who can count votes knows the chances for national limits are slim to none with Democrats in charge of Congress.

Instead, Obama left the door open to some kind of compromise on malpractice.

The president said he's willing to explore alternatives to taking doctors to court. In the past, he supported special programs in which hospitals and doctors are encouraged to admit mistakes, correct them and offer compensation. Studies have shown the approach can work, because doctors' refusal to acknowledge mistakes is one reason many families file suit.

Doctors have special reasons to be wary of the president's plans to overhaul the health care system.

Not long ago, doctors' decisions were rarely questioned. Now they are being blamed for a big part of the wasteful spending in the nation's $2.5 trillion health care system. Studies have shown that as much as 30 cents of the U.S. health care dollar may be going for tests and procedures that are of little or no value to patients.

The Obama administration has cited such findings as evidence that the system is broken. Since doctors are the ones responsible for ordering tests and procedures, health care costs cannot be brought under control unless they change their decision-making habits.

"Change is scary," said Dartmouth University's Dr. Elliott Fisher, a doctor turned costs researcher. "I think there is a fear of loss of autonomy, that someone is going to tell you what to do." Fisher collaborated on research that showed wild differences in health care spending around the country — and no signs of better health in the high-cost areas.

But Obama did not blame the doctors. Instead, he tried to woo them, much as he has done with recalcitrant foreign leaders.

"It's the equivalent of international diplomacy. He's got to make them feel like it's possible to have dialogue about what the future looks like," said Blendon. "I think he's starting out with the AMA, but before the summer's over he's going to reach out to a lot of the other groups."

Obama assured the doctors that his plan would provide them with objective information on what treatments work best, with new computerized tools to better manage their patient case loads, and with support for harried solo practitioners to form networks.

He promised that Washington would not dictate clinical decisions. And he asked the doctors to imagine a world in which nearly every patient has insurance coverage and they can devote their full attention to the practice of medicine.

"You did not enter this profession to be bean-counters and paper-pushers," Obama said. "You entered this profession to be healers — and that's what our health care system should let you be."

That line got him an ovation.

By RICARDO ALONSO-ZALDIVAR – 2 hours ago - reports on health care policy for The Associated Press.

Obama needs to take time and give Congress and the American People time to examine all the options and do the needed research about American Healthcare Reform, not push through another nightmare (costing 1 Trillion Dollars over 10-years), like the TARP and Omnibus Bills without reading or researching with the gun of immediacy to all our heads. Obama also needs to stop rewarding the organized labor, who spent $80 Million dollars getting Obama and the Democrats elected. Doing something just to fulfill your uninformed campaign promises is not a good enough reason to spend another Trillion Dollars and to do this wrong!! This time around is everyone's job to get this right and to stand up to the Obama Administration and Congress to get it right, or let it go until we have our ducks in a row and can afford the needed decisions. - Ask/Marion – Daily Thought Pad

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OBAMA BOOED BY DOCTORS IN ILLINOIS TODAY

Seems pretty funny to me that doctors booed the Obama and it was told by CNN today and it's not on the internet yet. Doctors in Illinois didn't like what he had to say and it was big on CNN. Thought I'd look into the Liberal side and see what was happening.

Oh, and what he meant about having it costing less as it goes along - is the Government going to make sure the elderly get their coverage or operations or whether they will tell them to go home and die is that what they mean about costing less as it goes along. Makes one wonder, doesn't it?

Seems a lot of doctors feel this will be offensive to them - and NO CAPS on the way people sue doctors looks to me that less men or women will want to be doctors in the future.

By: Teatime1 on AARP.org/blog

Source: Knowledge Creates Power

Posted: True Health Is True Wealth

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Understanding the House Democrats’ health care bill

Posted Tuesday, June 9th, 2009, at 10:30 am

Yesterday I posted and described the draft Kennedy-Dodd health care bill. Today I would like to do the same for an outline produced by House Democrats.

Here is a three-page outline of “Key Features of the Tri-Committee Health Reform Draft Proposal in the House of Representatives,” dated yesterday (June 8, 2009).

The three committees are:

• The House Ways & Means Committee, chaired by Rep. Charlie Rangel (D-NY). The Health Subcommittee is chaired by Rep. Pete Stark (D-CA).
• The House Energy & Commerce Committee, chaired by Rep. Henry Waxman (D-CA). The Health Subcommittee is chaired by Rep. Frank Pallone, Jr. (D-NJ).
• The House Committee on Education & Labor, chaired by Rep. George Miller (D-CA). The Health, Employment, Labor and Pensions Subcommittee is chaired by Rep. Robert Andrews (D-NJ).

The document suggests this is a joint product of the three committees and/or their subcommittees. My sense, however, is that it is Speaker Pelosi who is driving the bus. This is in contrast to the Senate, where the committee chairmen (Kennedy/Dodd and Baucus) appear to have the pen, in less well-coordinated efforts.

Kennedy-Dodd and the House bill outline are remarkably similar. Whether this represents House-Senate coordination or parallel thought processes is unclear.

I think the easiest way for me to present the House bill outline is in comparison with the Kennedy-Dodd bill. So here my description from yesterday of the Kennedy-Dodd bill, with today’s comparison to the House bill outline in red. I hope it’s comprehensible and useful this way. If you read yesterday’s post, you can skim the text in black and focus on the new text in blue.

Here are 15 things to know about the draft Kennedy-Dodd health bill and the House bill outline.

1. The Kennedy-Dodd bill would create an individual mandate requiring you to buy a “qualified” health insurance plan, as defined by the government. If you don’t have “qualified” health insurance for a given month, you will pay a new Federal tax. Incredibly, the amount and structure of this new tax is left to the discretion of the Secretaries of Treasury and Health and Human Services (HHS), whose only guidance is “to establish the minimum practicable amount that can accomplish the goal of enhancing participation in qualifying coverage (as so defined).” The new Medical Advisory Council (see #3D) could exempt classes of people from this new tax. To avoid this tax, you would have to report your health insurance information for each month of the prior year to the Secretary of HHS, along with “any such other information as the Secretary may prescribe.”

   The House bill also contains an individual mandate. The outline is less specific but parallel: “Once market reforms and affordability credits are in effect to ensure access and affordability, individuals are responsible for having health insurance with an exception in cases of hardship.”

2. The Kennedy-Dodd bill would also create an employer mandate. Employers would have to offer insurance to their employees. Employers would have to pay at least a certain percentage (TBD) of the premium, and at least a certain dollar amount (TBD). Any employer that did not would pay a new tax. Again, the amount and structure of the tax is left to the discretion of the Secretaries of Treasury and HHS. Small employers (TBD) would be exempt.

   The House bill outline also contains an employer mandate that appears to parallel that in Kennedy-Dodd: “Employers choose between providing coverage for their workers or contributing funds on behalf of their uncovered workers.”

3. In the Kennedy-Dodd bill, the government would define a qualified plan:
   1. All health insurance would be required to have guaranteed issue and renewal, modified community rating, no exclusions for pre-existing conditions, no lifetime or annual limits on benefits, and family policies would have to cover “children” up to age 26.

      The House bill outline is consistent with but less specific than the Kennedy-Dodd legislative language. The House bill outline would “prohibit insurers from excluding pre-existing conditions or engaging in other discriminatory practices.” I will keep my eye on what “other discriminatory practices” means in the legislative language. Does that mean that a health plan cannot charge higher premiums to smokers?

      Like the Kennedy/Dodd bill, the House bill outline would preclude health plans from imposing lifetime or annual limits on benefits: “Caps total out-of-pocket spending in all new policies to prevent bankruptcies from medical expenses.” This would raise premiums for new policies.

      The House bill outline “introduces administrative simplification and standardization to reduce administrative costs across all plans and providers.” I don’t know what this means, but suggest keeping an eye on it.

   2. A qualified plan would have to meet one of three levels of standardized cost-sharing defined by the government, “gold, silver, and bronze.” Details TBD.

      Same: “… by creating various levels of standardized benefits and cost-sharing arrangements…”. It also contains this addition relative to Kennedy-Dodd: “… with additional benefits available in higher-cost plans.”

      But note the “various levels of standardized benefits.” This appears to be more expansive government control of health plan design than in the Kennedy-Dodd draft.

   3. Plans would be required to cover a list of preventive services approved by the Federal government.

      This is unspecified in the House bill outline. We’ll have to wait to see legislative language. The House bill would require plans to “waive cost-sharing for preventive services in benefit packages.”

   4. A qualified plan would have to cover “essential health benefits,” as defined by a new Medical Advisory Council (MAC), appointed by the Secretary of Health and Human Services. The MAC would determine what items and services are “essential benefits.” The MAC would have to include items and services in at least the following categories: ambulatory patient services, emergency services, hospitalization, maternity and new born care, medical and surgical, mental health, prescription drugs, rehab and lab services, preventive/wellness services, pediatric services, and anything else the MAC thought appropriate.

      This appears parallel but is less specific for now: “Independent public/private advisory committee recommends benefit packages based on standards set in statute.” I find the “standards set in statute” interesting. It suggests that provider and disease interest groups will have two fora in which to lobby for their benefits to be mandated: Congress, and the advisory committee.

   5. The MAC would also define what “affordable and available coverage” is for different income levels, affecting who has to pay the tax if they don’t buy health insurance. The MAC’s rules would go into effect unless Congress passed a joint resolution (under a fast-track process) to turn them off.

      The House bill outline is silent on this.

4. Health insurance plans could not charge higher premiums for risky behaviors: “Such rate shall not vary by health status-related factors, … or any other factor not described in paragraph (1).” Smokers, drinkers, drug users, and those in terrible physical shape would all have their premiums subsidized by the healthy.

   The House bill outline says it would “prohibit plans [from] rating (charging higher premiums) based on gender, health status, or occupation and strictly limits premium variation based on age.” If the bill were to provide nothing more, this would appear to parallel the Senate bill and preclude plans from charging higher premiums for risky behaviors.

5. Guaranteed issue and renewal combined with modified community rating would dramatically increase premiums for the overwhelming majority of those Americans who now have private health insurance. New Jersey is the best example of health insurance mandates gone wild. In the name of protecting their citizens, premiums are extremely high to cover the cross-subsidization of those who are uninsurable.

   The House bill outline is silent on guaranteed issue and renewal. I’m going to make an educated guess that the bill includes these provisions as part of “other discriminatory practices,” and they have just left them out of the outline. Given the philosophy behind this outline (with which I disagree), it would be a striking omission. But for now, the outline says nothing specific on these topics.

6. The bill would expand Medicaid to cover everyone up to 150% of poverty, with the Federal government paying all incremental costs (no State share). This means adding childless adults with income below 150% of the poverty line.

   The House bill outline “expands Medicaid for the most vulnerable, low-income populations,” so we have no specifics other than that there’s an expansion. I cannot tell if this is expanding eligibility or benefits. The outline also “improves payment rates to enhance access to primary care under Medicaid.” I assume this means the bill would expand the Federal share paid of each dollar spent by a State Medicaid program on primary care, rather than the Federal government actually mandating specific payment rates to be implemented by States. Federal micromanagement of specific Medicaid provider payment rates was eliminated in the mid 1990’s.

7. People from 150% of poverty up to 500% (!!) would get their health insurance subsidized (on a sliding scale). If this were in effect in 2009, a family of four with income of $110,000 would get a small subsidy. The bill does not indicate the source of funds to finance these subsidies.

   The House bill outline has a sliding scale up to 400% of poverty. If this were in effect in 2009, a family of four with income of $88,000 would get small subsidy.

8. People in high cost areas (e.g., New York City, Boston, South Florida, Chicago, Los Angeles) would get much bigger subsidies than those in low cost areas (e.g., much of the rest of the country, especially in rural areas). The subsidies are calculated as a percentage of the “reference premium,” which is determined based on the cost of plans sold in that particular geographic area.

   The House bill outline is not specific on this point. I would not expect it to be – this is something you can tell only from legislative language.

9. There would be a “public plan option” of health insurance offered by the federal government. In this new government health plan, the federal government would pay health care providers Medicare rates + 10%. The +10% is clearly intended to attract short-term legislative support from medical providers. I hope they are not so naive that they think that differential would last.

   The House bill outline “creates a new public health insurance within the Exchange … the public health insurance option competes on ‘level field’ with private insurers in the Exchange.” There are no specifics on how the public plan would work, or on provider payment rates.

10. Group health plans with 250 or fewer members would be prohibited from self-insuring. ERISA would only be for big businesses.

    The House bill outline is silent on this point.

11. States would have to set up “gateways” (health insurance exchanges) to market only qualified health insurance plans. If they don’t, the Feds will set up a gateway for them.

    The House calls it an Exchange rather than a Gateway. While the Senate bill would tell each State, “Create a Gateway or we’ll create one for you,” the House bill outline says to each State, “We’re creating a single new national Exchange. You’re in it unless you develop your own State or Regional Exchange.”

12. Health insurance plans in existence before the law would not have to meet the new insurance standards. This creates a weird bifurcated system and means you would (probably) be subject to a different set of rules when you change jobs.

    The House bill outline appears to parallel the Kennedy-Dodd draft: “Phases-in requirements to benefit and quality standards for employer plans.” This means that new plans will be more expensive than old plans. It also means they’re creating a bifurcated system with all sorts of perverse unintended consequences for employment flexibility.

13. The bill does not specify what spending will be cut or what taxes will be raised to pay for the increased spending. That is presumably for the Finance Committee to determine, since it’s their jurisdiction.

    The House bill outline lists specific topics for changes to Medicare reimbursement:

    • Changing (how?) the Medicare reimbursement for doctors, called the “Sustainable Growth Rate” (SGR).
    • “Increasing reimbursement for primary care providers”
    • “Improving” the Medicare drug program. I won’t be surprised if, when I see the specifics, I disagree that their changes are “improvements.” In the past this has meant having the federal government mandate specific prices for drugs.
    • Cutting payments to Medicare Advantage plans.
    • Expanding low-income subsidies for seniors and eliminating cost-sharing for all preventive services in Medicare.

    The House bill outline also uses positive language to describe things that might generate budgetary savings from Medicare and/or Medicaid. The hospital readmissions point is specific. The first two points could increase or decrease federal spending, depending on the specifics.

    • “Use federal health programs … to reward high quality, efficient care, and reduce disparities.”
    • “Adopt innovative payment approaches and promote[s] better coordinated care in Medicare and the new public option through programs such as accountable care organizations.”
    • “Attack the high rate of cost growth to generate savings for reform and fiscal sustainability, including a program in Medicare to reduce preventable hospital readmissions.”
14. The bill defines an “eligible individual” as “a citizen or national of the United States or an alien lawfully admitted to the United States for permanent residence or an alien lawfully present in the United States.”

    The House bill outline is silent on this point.

15. The bill would create a new pot of money for state gateways to pay “navigators” to educate people about the new bill, distribute information about health plans, and help people enroll. Navigators receiving federal funds “may include … unions, …”

    The House bill outline is silent on this point.

This would have severe effects on the more than 100 million Americans who have private health insurance today:

• The government would mandate not only that you must buy health insurance, but what health insurance counts as “qualifying.”
• Health insurance premiums would rise as a result of the law, meaning lower wages.
• A government-appointed board would determine what items and services are “essential benefits” that your qualifying plan must cover.
• You would find a tremendous new disincentive to switch jobs, because your new health insurance may be subject to the new rules and would therefore be significantly more expensive.
• Those who keep themselves healthy would be subsidizing premiums for those with risky or unhealthy behaviors.
• Far more than half of all Americans would be eligible for subsidies, but we have not yet been told who would pay the bill.
• The Secretaries of Treasury and HHS would have unlimited discretion to impose new taxes on individuals and employers who do not comply with the new mandates. (The House bill outline is not specific on this point.)
• The Secretary of HHS could mandate that you provide him or her with “any such other information as [he/she] may prescribe.” (The House bill outline is not specific on this point.)

I strongly oppose the Kennedy-Dodd bill and the House Tri-Committee bill.

If this topic interests you, I highly recommend Jim Capretta’s blog Diagnosis.

Source: Keith Hennessey.com /Daily Thought Pad

Posted: True Health Is True Wealth

Related Resources and Posts:

• Healthcare: You Think Michael Moore Will Contribute? Don’t Hold Your Breath
• Here Comes Health Care Rationing
• Once Considered Unthinkable, U.S. Sales Tax Gets Fresh Look
• British Healthcare – Don’t Treat The Old – And Senator Coburn Warns The Same For USA
• Rights, Responsibilities and Healthcare
• Universal Health and Old People
• Social Medicine is Great*! (as long as you don’t get sick)
• Conservatives for Patient's Rights
• Obama's Attack on Medical Civil Liberties
• Socialized Medicine in cartoon form.
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