it means individuals and families buying coverage next year are going to spend an additional $300 to pay sales tax and it will go up to 500. that will make the most sensitive individuals. it is not going to make any sense to employers. so that is the sort of thing that we want to focus on again now. before we have a portability issue before it goes into effect. i also talked about the essential health benefits, the important benefits like how can we get people from here to there.

we are focusing on our job in the health plan community as we focus on improving things in identifying these problems. as i was thinking about the last discussion, it struck me that there are five policies that we should be paying attention to the premiums do not equal cost. we just released an out-of-network survey today, and the numbers being charged, individuals and providers that are out-of-network versus and network as well. affordability is not equal to subsidy. subsidy is an important part of affordability and i was very grateful for that.

but my scholarship helped me with the subsidies. the silo says we are going to do something on medicare, medicaid, then it gets shifted to the private sector individuals are worried about being able to purchase it and public programs are worried about able to being able to maintain it. aco's do not equal competition. we had a discussion about creating aco's without really getting in under the hood to look at where the competitive effects order.

and finally for all of you here this institution, as you well know, they don't give you a sense of what particular individuals were paying. so when we see this, that doesn't tell you what will happen to a 25-year-old. it doesn't tell you what will happen to a 54-year-old and i have to start looking at case studies to understand the impacts us what kinds of actions we should be looking at now to be able to transition to this new market to create affordability and to move the system forward. we are very excited about having this discussion, and the time for that discussion is now.

i look forward to your questions. thank you. >> good morning, everyone. i appreciate having this panel of men and women. [applause] i also come from washington. you know, 25 years in washington, we always have to be politically correct. except when it comes to basketball. i come from the university of maryland. my family are really big into

our school. my husband is getting over the loss of jerry williams. but i have to tell you we all watch the miami and duke game. i may have to be down here sooner than what you think. [laughter] i am going to try to keep to this, it is to talk to you about the affordable care act and its impact on employers and companies and businesses. what does this logic to that segment in our country how does

the impacts affect large employers? it's important to understand. there is a major industry for private sector care and private sector coverage. that is the employee base system. we have close to 160 million people who receive health care coverage. what that means is if you are a young student is about to graduate today, when you go look for a job come the first question you ask the employer is what am i going to be doing. but pretty quickly, you will ask, what are my benefits? you offer health care coverage? what is that when the cost? pension, benefits, you have a conversation about the job i

will be doing, what are my wages and benefits. employers have been doing this historically for decades and decades. employers come into the game of health care coverage for a reason. it was out of necessity, competition, and healthy workforce. making sure that individuals were healthy and can come to work every day. i would be remiss if i didn't say that there were tax incentives. tax deductions about offering benefits to the employees. if you are part of an employer-sponsored plan, that benefit is excluded from your income. there is a great deal of incentive, we are the only country that does this. we have a robust system fueled by employers and it is also part of of this.

how did the portal correct change that? wire businesses reacting in this way? welcome i think it's helpful to step back and talk about the primary goals. so how is that new number of 32 million uninsured americans when it comes to the system? one is the much talked about individual mandate. every individual in this country with some exception, in 2014, has to purchase health coverage of some sort or they could face a tax penalty. number two, you have heard a lot about the health insurance changes in market places, these were provisions set up in the law for states to step in and establish what is called these exchanges and the place where individuals can go and purchase coverage.

for lower income individuals, you have heard like subsidies and credits are important. through these individual exchanges from the federal government will do tax credits and subsidies. primarily for lower income americans for coverage all of this is linked together. you may be able to go to exchanges and get credit for subsidies to do this. all of these provisions are linked together.

to be candid, this is not so great. employers have always offered this in a voluntary manner the law has requirements on how this is offered. under the definition, it says that every large employer must offer coverage. the definition is if you have more than 50 employees, you have to offer coverage. you have to do a calculation. you can have as few as 20 or 25

employees, but you have to have this in a careful way. if you have 50 employers, you have to have coverage. a lot of mom-and-pop shops in donut shops and hamburger joints another critical point is they have to offer full-time coverage to a full-time employee. how is a full-time employee to find? and employee that works on average 30 hours per week per month. you work a lot more than 30 hours a week. it is. the incentive was that if we

lower it to 30 hours a week, more people will be given coverage. thirty hours is a pretty low standard. most employers, they have to make a decision. what about the unintended consequences of part-time workers in this country working 20 hours a week, lower reaches and no benefits? i have talked to several cabdrivers and restaurant workers and when i walk into a retail store, i think, how many hours a week do you work. i'm a health policy geek. so what does that coverage have to look like? standards of affordability as to what karen mentioned. it cannot exceed a certain amount of household income.

but we have to figure out how to we create a standard that is affordable. i have to figure out how is it affordable because it is not, again, in my ability to get tax credits. have to meet minimum value standards and not only the premium costs, but you cannot ask them to play a deductibles down and you have to be clear about coverage or not and what do the standards have to look like. it affects all employers. think about the millions of companies that have high turnover, they are having to take a hard look at this. the laws are not black or white. you hear a lot of media messages about this.

the second question i get is why don't employers drop the coverage and pay what is a full-time employee coverage. it's so much cheaper. why don't employers navigate. employers will never be out of the game. they are the engine in this country. what will happen? welcome i would like more wages and $2000 won't be enough. if you are in control, over your employers and employees -- the benefits that you are offering, you should stay in the system.

at the very least, it is confiscated. we just have to go up, it is also not just math. art and science and medicine and reasons that they offer employer-sponsored insurance. they have made time and effort to making sure they are helping to take care of you to part-time jobs for everybody doesn't work. it doesn't work for you, it

doesn't work for them, employees will be unhappy. you won't be able to staff your company or your business on 28 hour per week workers. not an easy interest this is having a major impact it will have an impact on you, whether you offer coverage or not and at what level and at what hours you work. i hope that we are able to achieve and think about the greed ways to stay in the game in a good way for you in your place to have a productive workforce. things have been hotly debated. all of these new provisions need

to be looked at and we can work together to make it happen. [applause] >> thank you for your work. why don't we start with the things that keep you up at night and what changes we face in what should be handled right away, and also, whether the policies they are that needs to be bipartisan. we have bipartisan agreements, and sir, why why don't why don't

you start what changes he would make. >> i'm very sad that you asked. i think it is a combination of things. clearly given the difficulty of moving things on capital here, i think that one needs to look at this from the standpoint of how do you make this better for affordability. there is a certain authority for these regulators to try to balance all the factors, i think they are working hard for this,

we want to get the lessons taken care of. whether taxer insurance reform and they didn't have anybody participate. we don't want to repeat that. that is why we are focusing on what can be done to avoid that. i put that ratio at five to one for least five years. okay, number two, i would look at additional transition provisions that can be leveraged to move small employers that may have very small benefits right now, to help them, not necessarily in one fell swoop, deductibles and coinsurance, they have been very thoughtful in thinking this out as well so far. but i would do some additional things.

>> that is very important. we talk about coverage, but we forget about other insurance. >> i have talked to a number over the last several years. but i want to do something, even if i can't do it financially. it's all in the eyes of the holder. it all rests on where they may be in. so i am focused on is how do we get the person into the system, that where they are not incentivize to drop. i want to characterize it with what makes sense and what doesn't. unintended consequences. small employers, individuals, it is the individuals buying coverage, small employers buying

coverage, medicare advantage. it is going to make a material difference in the benefits. we will hear from the seniors, and we should there is room on the regulatory side we need to look at how we get people into the system and how do we do it in a way that option one and option two can work. i am very focused on getting people in and making it as affordable as possible.

>> what keeps me up at night is generally my four year old what keeps me up is that. but as it is with insurance, what keeps me up is employer coverage and the balance of the private sector and medicare and medicaid and it's a great balance between our federal programs in our private programs. how do we keep employers happy and in a productive workforce i would change that to a

full-time definition. two allows small employers to plan out what they need. and i can hire those employees, up to employee number 51 event, and i can plan better. the second thing i would change as if i would strike 30 and i would put in 32 or 34 or 35. something that provides to offer coverage and higher wages. i'm very worried about what will happen to this country and the part-time population in this country of workers and there is a real concern here about what it's going to do. those are the two changes i would make. we are living in such a tough time in washington in 2013.

>> a market without health care reform has been keeping people to part-time. so we have large numbers of people that have more than one part-time job. so i am concerned we have to make sure that they have access to health insurance and appropriate subsidies. >> i cannot agree with war. there needs to be encouragement for them to offer coverage to part-time workers as well as the full-time workers. because the danger is if you are

a part-time worker, you may work 20 hours at one place in 20 hours at another. so your household income could be high enough you could not get credit or subsidy in exchange and so you're like, i can't go here or there. that is not a good outcome. i agree with you wholeheartedly that we should have more policies even if it is not as generous or they could have exchange with the systems. >> i would like to talk about this a little bit. we haven't gone into a full discussion yet, and we have hospitals and doctors and he made the point that we are a little afraid of the political process. unless there is a process in which we share shared the aid, we are talking about the whole system coming down, we are

putting that together. doctors and nurses and host country and hospitals out here, they have suspected that this is eventually going to get you less income and lowering the cost. it left employment in a very dynamic industry. we have had to pull down some of our overhead costs. >> i think you have put your finger on this. nobody really wants to talk about it.

if you look at the job growth, a substantial amount of it is health care. we are building on a system that we cannot sustain. so where do you have the rational process? you really need a rational process. what was talked about in the community for a long time is wrong we were very much involved in a coalition to identify ways of 2 trillion taken out of the cost of health care. medicare, medicaid, subsidies, tax expenditures, in terms of

the purchase of insurance. $17 trillion. how can we take one or two off of that not tomorrow, but over 10 years. and then what is the pathway to that. the discussion has been misdirected. what are we doing with the public-health challenges? these changes that miami has led in the public-health challenges. ..

can't look at that at the national level. you have to look at the state level, local level. so i think, donna, the incentives need to be at the state level. i don't mean this day back to unilaterally, the gathering stakeholders to look at the data, to look at the problems

that the state level and think about solutions. the thought we've had about days is if you go back to that 17 trillion that were spending nationally and you think about if that's what the cbo has projected, to the extent you done the cost curve, there's money on paper to do teams sharing and reword states for doing that. you also have the ability to look at total cost, not just medicare, medicaid. you has to very important question and i hope i've given you an answer that reflects the seriousness of your reflection. i just think we have to go back to fundamental principles. what's the problem, where's the best way to solve the problem? it's like a mathematical equation by physics problem as you all think about these issues at the university. we need to think about, what is the right level to have this

discussion? >> you're talking about fundamental reorganization of delivery health care. and people working out to their level, organizing care in the delivery system. what about individual responsibility? one of the things about an academic health centers have a doctor for every part of my body. this is a true story. i twist my ankle and i go to the ankle doctor. a very nice, young, untenured assistant professor looks at my ankle and says it probably twisted, but i think you ought to have an mri. he looked at me and dad must be the one in mri. it said that i know the difference in cost between the x-ray and mri. besides the x-rays down the hall and down the hall and i can have it in two minutes.

i'm sure he thought he would never get tenure. last night the point has wacky talk about this issue and how we'll handle the politics? are essentially less people in the industry perhaps are being organized in a different way and no anticipation of the kind of salaries they are padding the past past. but also something about regulatory reform the u.s.a. were spending a lot of money on the regulation side. >> we are. a lot of the statute on the books is done to the regulatory side. we spend a lot of time in washington talking to president obama's administration, health and human services where you were a secretary treasury and the irs and department of labor and i will say to your point

about how does this effect the individual or the employee, depending the system is it's going to be very complicated for individuals and employees in this country pathetically sad, and the the media starts going only get up and running by the fall in october because the idea is you're supposed to have coverage. unless you want a tax penalty can you require to have coverage. the trick will be figuring out where should i be? what is the right coverage for me? is largely based on income. can i go to an exchange? am i eligible? should i be on medicaid? while my spouse added, will my children receive credit their? gets complicated and technical on where you and your family can get coverage tomorrow going to have to, all of us here today to work in the health care sector, whether it's medicare, medicaid can have to think about an

individual point of view. puerto rico, how do i pay for clicks it's going to be a challenge in the next six to nine months before we get off the ground. >> i think the question that you post is a very interesting one from two days. one i think and give a thoughtful answer again just to sub event. i think we need to think about the issue of malpractice reform. lurch to the discussion has been focused on tort reform. i think we need to focus if we want to have this type is, we need to reward and protect physicians and hospitals practicing best practice and that means in the case of malpractice, albeit sent this for the physicians and hospitals to do everything possible to protect themselves is quite logical. just like fee-for-service, quite logical that the incentives are. we had to change that in the current malpractice structure

and protect doctors practicing best days. the other thing that occurred when you post that -- >> they don't have a federal ankle. try some new things. >> i think the reality is the best reform will be done with apple people coming together to say in a particular area we have variation in how do you get past tracked this? what are the standards for use? there's been discussion about that nationally as well as state-by-state. mark talked about this very compellingly. >> write nonstandard characters that protect you. >> exactly. that is a major shortfall. [inaudible] the other thing is consumers should be worried about in here this very rarely in the discussion, how much radiation a real exposed to?

only not the beginning studies about the fact that we're paying significant health care consequences associated with these incentives, which are to do everything possible. i think were at the bottom end of the understanding, but that's part of it from the patient did. >> if i could add another word when it comes to the individual x variant, they've fallen into next year, where should i give a coverage and how much is it going to cost? the next question is a look at these 32 million uninsured americans and the system is will i have a provider to be there and take care of me because all the assistance and reimbursement incentives are reassigned and a lot of the 32 million olney basic care, primary care, have never had the diabetes check with the blood pressure checked. a lot will be basic primary care. are we going to have enough providers and what is stenciled

abn? medicaid, insurance exchanges, will we have enough providers and facilities to go to? >> of us were prepared to take out the issues so everybody works up to their level, we have enough providers if we can expand the scope of this for everyone and you start yours appropriately and physicians assistants and all the other people we've been training. >> what a wonderful employment training agenda from the new economy and increasing productivity, what better way to start thinking about all of these issues that we rarely talk about when it comes to health care. >> the microphones are set up and we'd be happy to have our questions.

>> good morning. i am one of the cardiologists from fort myers, florida. the question i had this to us talk about affordability and access. affordability i think the affordable care act will provide all the insurance requirements that obamacare and everything will have a million people to the people who will be using health care service. but right now in this state, it's so difficult. it takes two to four months for me to see a family care physician. and we always have a good quality provider. at the same time, if you want to send your kids to med school, it is costing 50 to $60,000 a year, going to get almost 1 million in

a debt with these kids and you'll be talking about reducing payments for everyone. how are these kids going to feel that they want to go to med school and provide a good quality of care at the same time pay their bills? >> you have put your finger on one of the most important infrastructure issues that rarely gets top about. i went to college on scholarship. i would've gone to college otherwise, so i'm grateful to have done that. when you pose the question of how do middle-class kid ever think about going to medical school is that option closed out because the amount of debt they come out with it's just going to be impossible to manage. i think that is something i was not in health care reform and it seemed to be a little appetite for it at the time. i wish that we should be looking

at that. again, what incentives do you put in place? pattycake scholarships aligned with needs? how do you think about making sure these careers stay up into the best and brightest, which let me some financial subsidies. so that's why i'm thinking i've returned these discussions down closer to the ground to the delivery system, to the educational system, getting stakeholders involved. i don't want to sound like a pollyanna, but you can identify pathways and opportunities in the business community has a strong interest and i'm sure we'll talk about that as well but the education community and the entire stakeholder community. this is impossible to do in washington because you're not that close to the ground. i hope you continue to raise these issues and we can do something that could have devised the local discussion

dialogue and action. >> switch questions that can give our colleagues here an opportunity to answer. >> dr. norman, you mentioned something about the cost and everything in there and charges in office. medicare by default has become the reimbursement standard over the last 25 years. in 1985, heart surgeons who give back to dollars. navigate a thousand dollars and 75% of those have been filled. i think somehow the doctors have been pushed aside, not the insurance company, not the hospital and needs to be more transparency. the question is how do you think we can change that? nine out of 10 people in the united states get their health care from a smoker practitioner and in the new england journal two or three years ago, doing

all this other stuff, i don't know how that's going to change reimbursement. you all as insurance representatives are concerned about the high cost of going to charge. economic sustainability for private practice does make this. the question is how do you rectify lowball reimbursement because it's going to end up in a manpower shortage. you've are you've are not the doctors it anymore. >> this study we release today is about network charges. i wouldn't have mentioned that if we had seen something in the neighborhood of close to a benchmark. this seemed odd network charges 95% times medicare. we dealt with, we eliminated the outliers. for certain specialty services around the country. so that is clearly a problem that everybody has a stake in solving. two deposition problem you were

talking about, i agree with you. what we see help lance to around the country, which is exciting and here in florida, making sure it is repaired with positions, we are helping physicians with court nation care. not expecting physicians to do that in their practice, that giving them resources, whether it be nurse practitioners and other professionals to help you triaged, help to follow a good diet plan is always you have it filter medication. that's just one example of the kind of thing that goes on. making sure that we are partnering with you as a physician to extend your reach. now with the reimbursement mechanism, moving away from the retrospective system to bundling and so on a tank positions can be more satisfied with that and

work in partnership on the quality side and that's what patients want as well. >> what people don't understand is eight times medicare node equal what we got in 1985. people go to school -- my point is i don't think anybody understands that. >> is really complaining that the payment for that procedure is going down. but as you well know, the ama running a system on actual costs have set the price for medicare. and because we have a system, you get caught up in that in some opec visionaries don't have a volume and range -- there's no way they can survive under the

current fee-for-service system. there's something larger at it got to be part of any system. >> i think what's really interesting come is being held plants making sure that they can help physicians who want to stay in their offices a single practitioners are one other part tichenor and giving them support in terms of coordinated care so that physicians don't have to do all that sells. >> we just need to ensure medical care for everyone. >> will take the next question, thank you. very important point. >> unexercised teleology major and we seem to be talking about prevention and wellness in a very vague manner and we all seem to talk about it only from the perspective of stopping a disease that's happened from progressing to a catastrophic disease. but the incentives to prevent this from happening, diabetes, high cholesterol, things like

that. we have some incentives in the way of exercise programs, both with policy and subsidies to provide a matter of making us sicker. >> absolutely. i will say briefly one of the points you may have heard me discuss with the fact that particularly an employer system, where players spent a lot of time thinking about wellness, certainly if i have -- let's say when parts shop and i've older manner that they irenic haircutter rate and i have a lot of young single female workers, been able to design a benefit package that works for the population you have this incredibly important. when i look at wellness, they do have a broad understanding. it isn't just cancer, diabetes or heart disease, but are you exercising, maintaining your weight, reducing smoking and use a tobacco products. they look at the whole panoply

of issues that makes a healthy person. that's the innovation i hope continues. there are incentives under the affordable care act to do those wellness programs. its built-in without going into technical details and to some of affordability issues and i personally hope it continues than as part of the consumer directed movement. >> we tacked about senator daschle's leadership. there actually is a new report on that subject and what employers are doing around the country and i thought were looking out. morning. first i want to congratulate all the women on the panel. i'm very proud of you. also, everything is related to the elephant in the room that was only briefly mentioned in the lawsuit. you know, you want a physician of pressure to perform

procedures that sometimes we don't even agree, but were forced by the family is an patients demanding that can you feel like you have to do it just because otherwise he will be sued and then everything you've worked for will be gone. nobody seems to be worried about that. i understand the expansion, but it ended the day, the position is the one that gives food and that's wrong. that's completely wrong. [applause] that's a very good point. the states have taken up the issue around the country, that he can, i guess we haven't found a way for the fed to intervene in that issue because of the constitutional question. very much a state issue.

>> and also, it is hard right now in washington to move to policy discussion and we need to partner at a space through efforts to begin to get traction on these kinds of reforms and this is one of the most thinks we can do. >> p. she safety movement has driven down the number of lawsuits in this country. it's really had an impact done correctly, physicians, nurses have taken it seriously and that certainly has to be part of the overall days. and of course incentivize fat. >> i think it's been difficult politically to take the next step. i think a person who raised the question is absolutely right. from the standpoint of a position today, you're worried those who are wonderfully trained, but don't feel they are owed gb lan tao.

you can go right down the specialty level and latter and i think we need to confront that sooner rather than later. if we want to have a safe system that practice is best practice, we have to align the incentives to achieve that. >> in some ways to give the governor is a list of things to do in addition to whether they put the exchanges on other things, they've got to see this is a larger strategy. >> tremendous position to bring stakeholders together as hard to walk away from governors. >> to talk to governors at all? to the implement -- you've been talking to people thinking i'm going to let the feds come in with the exchanges. what are you saying to them? >> this is a setup because their government is trying to figure out whether he's going to do the legislature. >> in terms of what the statute

authorized them for the states to move forward on exchanges, they're all in different places. some are moving ahead aggressively and early and are getting underway. summer stomach and decisions. not sure whether they'll do the exchange are not in others a flat out said no. >> why would they not do the exchanges? i would they turn over ownership to the fans? >> that's an interesting question. you look at whether or not to establish exchanges, in doing exchange coupled medicaid expansion, certainly there's no question there's political issues going on, but also every governor is a major budget issue. establishing exchanges in the infrastructure it takes, expanding the medicaid program has a great deal of federal support her back, but there were be a long-term mission. it's a variety what does my state for quite? how heavy of a burden is this going to be? one day not talked about is it's not like the uninsured are

distributed across the country. they are concentrated in florida, louisiana, texas. whenever intense about our first experiment for utah has an exchange, there is very few uninsured, not to the levels here in florida or texas. a lot of them look from a budget point of view of what it means to expand medicaid into the exchanges. the one thing that will prompt governors to step in and establish an exchanges because they won't necessarily want the federal government to come in and the business of insurance is always been at the state level. the business of insurance has always been at the state level. it is a state run local enterprise. i'm sure you would agree with this. there's a lot of good reason for having it delivered at the local level. you are former secretary.

if you had to come in and or defend states, that's a very tall task for washington to take on. it remains to be seen, but there's a lot of political and budget issues. eventually the states will run their own insurance program. >> one postscript. to create this metal partnership so you can scale up as you're ready so it either/or. >> it sounds like i was in in the obvious way. they listen to states that wanted to get their couldn't get there. >> what's the one governors always use? flexibility. >> they actually used the word lock grants. send me the money. >> good morning. florida board of nursing and action coalition working to implement the institute of

medicine recommendations on the future of nursing. says scope of this, there is a war on nurses. is there ever a possibility that through the affordable care at our federal legislation are rules that the scope of practice could be equalized throughout the country? >> licensing at the state level. >> there are some things that cms can do. i actually know the technical answer to this. they're in the process of reviewing or redoing and there are some things that private insurance companies could do and many of your company's verdict on this. so we are seeing in the net in this area. >> i do think there's things they can be done in terms of anonymous or the scope of this, the reimbursement.

the other and i hope you don't always feel there's a war on nurses. the other thing often not talked about is we often talk about and you heard me talk about the 32 million coming in. but it doesn't solve all of our country's problems. there's still millions of uninsured even if the law works perfectly. there were still be millions of uninsured and uncompensated care. the ability to get coverage, all of that is still going to exist and i don't know -- i know it's a big concern is we talk about uncompensated care and that and providers. i still think we have a lot of issues to address. >> this year the florida legislature and the organized medicine has actually escalated their fate against nurses having the ability to practice. >> there's more of you than

there are of them. [laughter] >> john hirsch. i'm not a medical doctor, but i work with them. listening to some and are so far, i have heard a clear motivation of movement away from fee-for-service payment. from what i've seen in working with medical doctors, personalities issue associated with that, which is an motivation to work hard. the more you do, the more you get. i'll take that call at 7:00 p.m. on friday night. if the compensation structure is changed, that's probably old news, sent to you been thinking about. there is a second that all aspects but i think warrants some discussion and that is that innovation in medicine takes place both in academic institutions and in private is with people tinkering because if

they tinker it gives them a competitive advantage in their practice will be rewarded. what they give you a simple dirty second example from ophthalmology. he used to be with cataract operation, it is common to have the type perforated in the course of a procedure and a patch. ophthalmologist in private is tinkering figured out rather than making a puncture wound, you make more of a slicing wood at the inter-ocular pressure would close the wind come in there you don't need a stitch stitch and you don't need a patch and people who figured that out soonest at cataract patients patients and their market talking about sin or financially benefited from that. so my point is innovation comes from academic setting in private days. if we take away that incentive, if i come up with an innovation, sure it will feel intrinsically good, but intrinsically a

benefit us all and theoretically have a diminution in the rate of progression of technology and improvements in the private sector. >> i think that point is very well made. in fact, on the next panel they'll be talking about the transformation and specifically apologize big fee-for-service is harder than anyone out there. but let's leave that issue to the next panel. i am told i have to cut this off. i apologize to those of you that want to ask questions, but these two very distinguished panelists who have come a long way to be with us today, let me thank karen -- [inaudible] clap act ..