On Evaluating Claims

Numerous claims have been made about healthcare reform and The Affordable Care Act. I have found that three important rules apply in evaluating them:

  1. All opinions are not equal. Some are better informed.
  2. Partisan opinions are most likely to be just confirmation bias, and almost certainly wrong.
  3. All arguments should be investigated thoroughly. There is no substitute for research and objective, non partisan analysis.

The Take Away: Put aside any political leanings, and do the legwork, or recuse yourself.

 So What’s My Position?

This blog is concerned strictly with marketing and service issues of the financial sector. I am not involved in the politics and do not argue political positions or ideology. I neither support nor oppose either political party’s platform. Where issues involving healthcare are impacted by government policy, I simply research and elucidate them to provide information, analysis and perspective.

Yet, after all the time I have put into researching and analyzing the issue of healthcare delivery and costs, it is disparaging to read some of the misinformed nonsense that is advanced as factual information.

Here are some of the whoppers:

1. “The ACA Is the Biggest Tax Increase in History”

Claims: First, taking all the partisan spin out of it, the Individual Mandate is not a tax. It is a modest penalty and  not enforceable under either the tax code or civil law.

Fact Check: But how much revenue would it actually raise? According to :

This is so stupid it hurts. But Josh Marshall says that what comes next is even more brain dead: Republicans are now saying it’s the ‘biggest tax increase in history’ — either of America or the universe of whatever. But this is demonstrably false.

The Congressional Budget Office says the mandate penalty will raise $27 billion between 2012 and 2021. $27 billion over a decade. Anybody who cares to can do the math. But if you want to call it a ‘tax increase’ — which is debatable — it’s clearly one of tiniest ones in history.

What if you factor in all the the taxes in the bill? Treasury Department  tax analyst Jerry Tempalski has examined the 15 significant tax increases  since 1950/, and  estimated the size of all of them as a percentage of GDP.  PolitiFact used the same methodology to estimate the eventual size of ACA. The result places it only tenth on the list:

The ACA does include new taxes, but most of them fall on high earners and corporations, not the middle class.

2. “The ACA Will Kill Jobs”

Claims: The reasoning is that forcing employers to provide insurance for their employees will raise their costs, and that they’ll cover those costs by cutting wages and other compensation, and ultimately by shedding jobs. But is that true?

Fact Check: As reported in Forbes, The nonpartisan Urban Institute studied what has happened in Massachusetts, whose health reform law, passed in 2006, is broadly similar. It found no evidence whatever that health care reform, and mandated coverage, killed jobs:

There is no evidence of a more pronounced decline in overall employment in Massachusetts than in the rest of the nation over the 2006-2010 period, nor is there evidence of a more pronounced decline among the small firms, industries, and workers, where such declines would be predicted if health reform had dampened economic growth in the state. Although there are differences in the details between the Massachusetts health reform and the ACA, there are broad similarities that indicate that the impacts could be roughly similar under the ACA. The evidence from Massachusetts would suggest that national health reform does not imply job loss and stymied economic growth.

The Urban Institute first studied whether the Massachusetts law and the federal one were alike enough to draw conclusions from the state’s experience. It determined they were. It then looked at trends between 2001 and 2010  in both health insurance coverage and employment, in Massachusetts and in four similar states and in the nation as a whole. It also looked at employment in small businesses as well as large ones, and found no great differences at any level. And it found that “there is no evidence that younger and lower-skilled workers have been more likely to lose employment under health reform in Massachusetts relative to trends in the rest of the nation,” nor has there been any disproportionate shift to part-time work. All major employment trends looked pretty much the same in Massachusetts as elsewhere.

3. “Obama’s Plan Will Increase Medicare Premiums”

Claims: This claim comes from newspaper ads and mailers from a conservative group. “The “plan” it refers to is actually designed to produce lower prices for low-income Medicare Part D beneficiaries and taxpayers. The mailers also include alarming claims that “Obama is trying to radically change” the Medicare drug program and that the “devastating” impact would include an increase in prescription drug premiums “for millions of seniors” of “up to 40%.”

Source: American Action Forum, a 501(c)(3) organization that produced the study, is a sister organization of American Action Network, a 501(c)(4). The American Action Network was launched in 2010 by former GOP Sen. Norm Coleman of Minnesota. Its sister policy organization, American Action Forum, is headed by Douglas Holtz-Eakin, a former adviser to Sen. John McCain’s 2008 presidential campaign. AAN said it would spend about $1 million for the print materials and web ads. it does not have to disclose its donors, and spokesman Jim Landry said the group would not do so when we specifically asked whether this campaign was being funded by the pharmaceutical industry.

Fact Check: House Democrats describe the bill as one “that would save the government billions by reducing Medicare Part D drug costs for taxpayers” and “eliminate a sweetheart deal for brand-name drug manufacturers that allows them to charge Medicare higher prices for millions of low-income enrollees.” Democrats on the House Energy and Commerce committee say the measure is expected to save $112 billion over 10 years, according to the CBO, and, they say, it “would help avert Republican efforts to end Medicare.” The messages are referring to the Medicare Drug Savings Act of 2011 (H.R. 2190), which was introduced by Democratic Rep. Henry Waxman of California on June 15. Related legislation was introduced in the Senate on the same day by Sen. John D. Rockefeller.

The Democrats’ bill would require drug companies to pay a rebate for prescription drugs sold to low-income Medicare Part D beneficiaries. Most of the low-income beneficiaries are dual-eligibles, meaning they’re eligible for both Medicare and Medicaid. Prior to Part D’s creation in 2006, those beneficiaries received drug coverage through Medicaid, which requires drug manufacturers to pay a rebate. The Medicaid rebate is generally a better deal than what Medicare drug plans secure through negotiations with manufacturers. So the legislation is designed to implement a Medicaid-like rebate for the dual-eligibles plus other low-income beneficiaries on Medicare Part D. In other words, the government — and beneficiaries — pay less for drugs and the drug companies make less money. About 37% of Part D beneficiaries — 9.9 million seniors — receive low-income subsidies, and about 7.5 million of those are dual-eligibles, according to the nonpartisan Kaiser Family Foundation. Drug manufacturers would have to offer the rebates in order for their drugs to be covered by Medicare.

Whether drug companies would increase prices to others in response is a matter of conjecture, about which experts have differing views. There’s no acknowledgment that the 40%  increase claim comes from a study produced by a partner of the conservative group behind these messages. These ads and mailers from the American Action Network also make the greatly exaggerated claim that the legislation would “balance the budget on the backs of seniors.” Even if the bill achieves the estimated reduction in government spending, it would amount to a very small fraction of the total deficit.

The analysis done by Holtz-Eakin and Michael Ramlet of the American Action Forum, AAN’s policy arm, claims that this would raise costs because the drug companies will pass along some of the cost of the rebates to beneficiaries, leading to higher premiums and out-of-pocket costs. But Gerard Anderson, director of the Johns Hopkins Center for Hospital Finance and Management, also reviewed the legislation and said he didn’t see evidence that costs would be shifted to seniors. He said in a letter to Waxman that expanding the rebate to low-income Medicare beneficiaries would “lower the out of pocket costs and premiums for all Medicare enrollees,” and that if drug companies sought to cut costs because of the rebate program, they would likely cut their marketing budgets.

According to FactCheck.org:

We can’t predict how exactly the legislation would actually affect drug prices or seniors’ costs. But we can say that the AAN messages have been contradicted by Anderson, and views of the legislation vary greatly. The president of the Medicare Rights Center said in a letter to Rockefeller and Waxman that the bill was a “crucial cost-saving measure that will support other initiatives to reduce the deficit while protecting vulnerable populations who can least afford an increase in the price of health care.” The center is a nonprofit consumer organization for Medicare beneficiaries, and its president, Joe Baker, is a former New York state deputy secretary of Health and Human Services under Democratic Gov. David A. Paterson.  AARP also supports the legislation. The conservative American Enterprise Institute, on the other hand, agrees with AAF’s cost-shifting analysis, saying: “Part D plans may not be able to negotiate prices as low as they were before the rebate policy, necessitating increases in premiums or changes in the benefit offered by plans (for example, through more restrictive formularies or higher copayments).” AAN also referred us to a briefing paper that said “[c]ommercial drug pricing may increase” as a result of these types of changes. We also will note that while the ads say premiums would increase “by up to 40%,” that’s the upper estimate in the study, based on costs being passed along only to non-low-income beneficiaries. The Holtz-Eakin study says premiums would go up by 20% if “applied evenly across the Medicare population.” And the study is less dire-sounding than the ads. The report concludes that the legislation “would likely raise monthly premiums for seniors by between 20 to 40 percent,” rather than saying definitively, as the mailers do, that the “price controls would be devastating.”

For perspective, the average monthly premium for Part D plans is expected to be $40.72 in 2011, a 10% increase from the 2010 average and a 57% increase from 2006’s average premium of $25.93. That’s according to a report by the Kaiser Family Foundation, which also said that while average prices were going up, there was variation in price changes among the plans offered.

4. “Study: ACA Is Expected To Add $340 Billion To $530 Billion To Federal Deficits.”

Claim 1: Right-wing media are touting a study claiming the health care reform law will not lower the deficit, but rather increase it by more than $300 billion. According to the cited study:

The Affordable Care Act (ACA) enacted in 2010 will significantly worsen the federal government’s fiscal position relative to previous law. Over the years 2012-21, the ACA is expected to add at least $340 billion and as much as $530 billion to federal deficits while increasing federal spending by more than $1.15 trillion over the same period and by increasing amounts thereafter. These adverse fiscal effects are not everywhere understood because of widely circulated analyses referencing scoring conventions of the Congressional Budget Office (CBO) and the Medicare Trustees, which compare the health care reform legislation to a baseline scenario that differs from actual law.

Moreover, there is substantial risk that the ACA’s costsaving provisions will not be enforced as currently specified. To avoid worsening the federal fiscal outlook, legislative corrections are required before the ACA’s provisions become fully effective in 2014. Roughly two-thirds of the law’s subsidies for health insurance exchanges must be eliminated to avoid worsening federal deficits and the entirety of their costs eliminated to avoid further increasing federal health care financing commitments. [Mercatus Center, 4/10/12]

Claim 2: The Study’s author Blahous states that: conventional Health Care analyses involve “double counting” of proposed Medicare savings. According to The Washington Post:

President Obama’s landmark health-care initiative, long touted as a means to control costs, will actually add more than $340 billion to the nation’s budget woes over the next decade, according to a new study by a Republican member of the board that oversees Medicare financing…The study is set to be released Tuesday by Charles Blahous, a conservative policy analyst whom Obama approved in 2010 as the GOP trustee for Medicare and Social Security… “Does the health-care act worsen the deficit? The answer, I think, is clearly that it does,” Blahous, a senior research fellow at George Mason University’s Mercatus Center, said in an interview. “If one asserts that this law extends the solvency of Medicare, then one is affirming that this law adds to the deficit. Because the expansion of the Medicare trust fund and the creation of the new subsidies together create more spending than existed under prior law.”

Blahous acknowledged that his analysis departs from budget conventions, which, he said, make sense for the most part. He said that in this case, however, those rules do not fully illuminate the financial impact of the health-care law, since they permit what conservative critics have dubbed a “double counting” of proposed Medicare savings. [The Washington Post4/9/12]

Source:Conservative analyst Charles Blahous, citing a study by the Mercatus Center at George Mason University. In fact,  Mercatus Center is a highly partisan Koch-funded organization, that the Koch Foundation confirms: “has been a Charles Koch Foundation grant recipient “for more than 25 years.” From the Koch Family Foundations website:

For more than 25 years, the Mercatus Center at George Mason University, a Charles Koch Foundation grant recipient, has sought to bridge the gap that often exists between economic understanding and real-world decision-making. Mercatus applies scholarly research to problems facing policy makers. Bringing together a global network of scholars and experts, Mercatus provides policy makers with the economic tools to make sense of today’s most pressing issues. [Koch Family Foundation, accessed 4/11/12, via Think Progress]

Fact Check: Economic experts dismissed the study, saying it uses “old, discredited arguments.” According to New York Magazine the study “does not meet the standards of your typical university economics paper.” In a post titled, “The Bogus Obamacare-Deficit Study,” New York magazine columnist Jonathan Chait argued that Blahous’ paper is “not even remotely legit” as it “was published by the Mercatus Center, a Koch-funded organization that produces some quality work as well as a fair amount of schlock that does not meet the standards of your typical university economics paper. This paper is an example of the latter.” Chait continued:

Blahous is the Republican trustee for Medicare, so that title offers the hook for a paper he writes that, by adopting some mighty odd hypothetical scenarios, says that Obamacare will boost the deficit. Blahous’s government position gives the claim enough juice that it can be pitched as a “study” by a government official, as opposed to just another Republican-authored polemic, which would never receive such prominent or relatively credulous coverage. The next step is for conservatives to adopt Blahous’s figure as the “true” figure — but of course never to apply his strange assumptions to the GOP budget or to any other proposal — and browbeat the media into citing that alongside the CBO figure, for “balance.” [New York4/10/12]

Democratic Medicare Trustee Robert Reischauer said of his colleague’s study:

Under accepted CBO and OMB scoring practices, legislated reductions in Medicare HI [hospital insurance] spending both reduce the deficit and strengthen the HI trust fund. That has been the case under both D and R Congresses and administrations. Chuck’s “revelation” is not a new charge. Some argued this point when the ACA was enacted. It remains as misleading today as it did earlier. [New York4/10/12]

Center on Budget and Policy Priorities senior fellow Paul Van de Water wrote that Blahous “guss[ied] up old, discredited arguments about the budgetary effects of health reform. But his paper adds nothing new to the debate.” Van de Water continued:

Blahous claims the Congressional Budget Office’s cost estimate for the health reform law “double-counts” a considerable portion of the law’s Medicare savings. By subtracting these savings, Blahous asserts that — contrary to CBO — health reform increases the deficit.

But there’s no double-counting involved in recognizing that Medicare savings improve the status of both the federal budget and the Medicare trust funds. The outlooks for the budget and for the Medicare trust funds are two different things; some changes in law may affect one and not the other, but other changes affect both.

CBO estimates that health reform will modestly reduce the federal budget deficit. The Medicare actuary says that health reform will extend the solvency of the Hospital Insurance trust fund by eight years.

That’s no different than when a baseball player hits a home run: it adds to his team’s score and also improves his batting average. Neither situation involves double-counting.

CBO has accounted for deficit reduction in exactly the same way in previous Congresses, under both political parties.  Until opponents of health reform latched onto the notion, no one accused CBO of faulty accounting.

CBO has accounted for deficit reduction in exactly the same way in previous Congresses, under both political parties. Until opponents of health reform latched onto the notion, no one accused CBO of faulty accounting.[Center on Budget and Policy Priorities, Off The Charts,4/10/12]

Former Center for Medicare and Medicaid Services director Donald Berwick criticized Blahous’ study, saying: “The economist who’s coming up with this new standard, he’s simply arbitrarily abandoning a standard that the non-partisan CBO uses and has used for years.” [Talking Points Memo, 4/11/12]

In response to charges of “double-counting” in 2009, economist Dean Baker wrote at the time:

The reality is that the government faces multiple budget constraints. Savings in the Medicare program allow it to meet two of them.

The targeted savings would reduce spending in the program. According to Medicare’s chief actuary, these savings would give HI enough money to pay its bills through 2026 rather than the 2016 date when the program is now scheduled to face a shortfall.

Since Medicare is included in the overall budget, savings in the Medicare program also reduce the budget deficit. If there is a concern that we can only finance health care insofar as we are able to keep the budget deficit within certain limits, then the savings in Medicare will relax this constraint also.

There is no double-counting in this story. The government’s budget is structured so this multiple constraints must be met. Savings in the Medicare program will allow for this. [The American Prospect, Beat The Press, 12/29/09]

From a Washington Post Fact Checker post on claims of “double-counting” of Medicare savings:

You may have $1,000 on deposit at a bank. Those are certainly your assets, but the bank looks at that money differently: money to make more loans. It’s the same $1,000 but it is counted differently on your books and the bank’s books.

A similar thing is going on here. The health care law reduced predicted expenditures for Medicare by nearly $500 billion, resulting in budgetary savings that the law uses to help pay for the health care changes. That’s the money in the bank; it means the U.S. government will not need to set aside as many Treasury securities to fund Medicare.

Meanwhile, because Medicare spending has been reduced, the solvency of Medicare has been extended. That’s the other side of the ledger — the bank’s view, so to speak. The accounting for Medicare solvency is a different matter than the current spending in the budget, though it has implications for the long-term budget health. [The Washington Post,3/14/11]

CBO: Health Care Reform Lowers The Deficit By More Than $100 Billion. In March 2011, the Congressional Budget Office and Joint Committee on Taxation issued a joint report saying that “[o]n net, CBO and JCT’s latest comprehensive estimate is that the effects of the two laws on direct spending and revenues related to health care will reduce federal deficits by $210 billion over the 2012-2021 period.” The CBO subsequently determined that the Obama administration’s decision to indefinitely suspend implementation of the portion of the Affordable Care Act that enacted the CLASS Act lowered the deficit savings of the Affordable Care Act by $83 billion. [Congressional Budget Office, 3/30/1110/31/11]

5. “ACA will stick taxpayers with hundreds of billions in new costs to implement President Obama’s healthcare exchanges.”

Claims: The argument based on a new analysis by the American Action Forum is that states that decide to dump Medicaid beneficiaries will shift the cost for insurance subsidies to federal taxpayers. The report claims:

Suppose that every state takes advantage of this opportunity, and that every individual who is either on Medicaid or would be eligible for the expansion actually moves to the exchanges. The federal government would save as much as $130 billion in Medicaid in 2014, but it would be on the hook for $230 billion in new insurance subsidies. The net bottom line: a $100 billion annual expansion in federal costs.

The American Action Forum points out that not all states will likely make the leap, but claims that even if only a portion choose to, the costs overs 10 years will be astronomical:

Of course, not all states may forego the expansion, without doubt fewer than 100 percent of those eligible will take up subsidies, and actual insurance choices are impossible to foresee perfectly. Accordingly, the net cost will be lower than the full $100 billion, but it seems safe to say that the ACA will leave the taxpayer on the hook for an additional $500 billion or so in federal costs over the first 10 years.

Source: The American Action Network is a 501(c)(4) issue advocacy organization that focuses on promoting what it styles as “center-right policies.” It was established in February 2010 by Douglas Holtz-Eakin, a former adviser to the presidential campaign of Senator John McCain, and former Republican Senator from Minnesota Norm Coleman. They often run issue ads that identify candidates that support or oppose the policies advocated by them.

American Action Network was heavily involved in the 2010 elections. The group hoped to raise and spend $25 million and it slightly exceeded that goal, topping out at $26 million. It was the second biggest spender among all outside spending groups in the 2010 campaign cycle, according to the Center for Responsive Politics. Most of that money was spent on TV ads and other forms of electioneering communications. The group got involved in 23 House and five Senate races. The group focused most of its resources in 2010 targeting Democratic candidates for defeat, particularly in the battleground states of Pennsylvania ($2.5 million) and Virginia ($2.3 million).

In 2011, the group spent nearly $100,000 in New York’s special House election to help Republican Jane Corwin in a three-way race with Democrat Kathleen Hochul and Tea Party candidate Jack Davis. Hochulwon.

For the 2012 elections, the group is expected to spend “in the high tens of millions,” according to theNational Journal. As we wrote in August, American Action Network spent close to $1 million on misleading newspaper ads and mailers attacking President Obama and Democrats on Medicare in 22 districts represented by Republicans in 14 states. Jim Landry, spokesman for both organizations, told us that the groups’ primary focus will be on health care and the economy.

Fact Check:  For states that fail to establish exchanges, the federal government will establish an exchange to serve their residents, who otherwise would have no way to obtain subsidies to reduce the cost of their insurance. However, it is highly unlikely that

The New York Times describes the exchanges as follows:

The exchanges will essentially be online marketplaces for private plans that provide a package of essential benefits and consumer protections like guaranteed coverage for pre-existing conditions. They will compete to sell policies to individuals, families and small businesses. Anyone can use the exchanges to gain the benefits of comparative shopping, but most customers are expected to be individuals and families with incomes between 133% and 400% of the federal poverty level. They will be eligible for federal tax subsidies to make insurance affordable.

Many states are well on the way toward setting up exchanges, a complicated process in which governance procedures must be established, standards must be set for the plans that will compete and new information technologies put in place. The big uncertainty is how many Republican-led states will refuse to set up exchanges either because they adamantly oppose all aspects of the reform law or because they are reluctant to spend any time, effort or money to set up a mechanism that they hope Republicans will repeal after the November elections. That sounds like wishful thinking. States would be foolish to rely on it with deadlines fast approaching.

States must tell the secretary of health and human services by Nov. 16, just 10 days after the election, whether or not they plan to set up their own exchanges. The secretary must then certify by Jan. 1, 2013, whether states are on track to start enrolling people by Oct. 1, 2013, and to actually open for business on Jan. 1, 2014.

The Obama administration, which is eager to see the law implemented effectively, seems willing to accommodate any states that will make a good-faith effort. On Friday, the secretary, Kathleen Sebelius, announced that, in addition to grants already made to 34 states and the District of Columbia to plan their exchanges, she would open up additional financing sources that could be used even after the original start-up deadline. She also pledged to work closely with the states to tailor a federal exchange to meet their needs and a plan for transition to state control.

That sounds like a deal that no responsible elected official should pass up in the quixotic hope that the reform law will somehow go away.

3 Lessons

The United States has a healthcare problem that it cannot continue to ignore, deny or politicize.

1. Healthcare Costs Drive the Deficit: According to Ron Shinkman of FierceHealthFinance.com:

The U.S. healthcare system’s lopsided delivery costs compared to the rest of the world is the primary driver behind the nation’s long-term budget deficits, the Center for Economic and Policy Research (CEPR) has concluded.

“If the U.S. can get healthcare costs under control, our budget deficits will not rise uncontrollably in the future. But if we fail to contain health care costs, then it will be almost impossible to prevent exploding future budget deficits,” the CEPR declared Thursday in a statement.

The CEPR has projected that without the ACA in place, debt as a percentage of gross domestic product will be roughly three times higher by 2090. The CEPR has created a budget calculator to compare the U.S. healthcare spending against the rest of the world and long-term deficit trending. For more information:

– read the CEPR statement
– use the CEPR calculator
– read the White House blog post

2. The ACA is Just the First Step In an Ongoing Process: It is amazing is that even in an atmosphere of extreme partisanship and denial, fledgling first steps have been taken. The ACA is in fact a product of bipartisan effort, with many of its solutions originating on the Republican side. The idea of an individual mandate originated with the conservative Heritage Foundation in 1989, and in 1993, two different Republican-introduced health care reform bills contained an individual mandate.

3. The ACA is Not “a Perfect Solution.” Rather, it are an experiment based on the Swiss model that was field tested in Massachusetts.  In both instances, the experiment has been largely successful in doing what it set out to do – extending access to healthcare while retaining quality of care.

But the plan is not an end-all solution for cost containment. The Obama Administration has touted the ACA’s cost savings, noting that it would save as much as $143 billion between 2010 and 2019, pointing out in a blog post that “The Affordable Care Act will reduce the deficit: its costs are more than fully paid for.” However, in a May 2010 presentation on “Health Costs and the Federal Budget”, the CBO stated:

Rising health costs will put tremendous pressure on the federal budget during the next few decades and beyond. In CBO’s judgment, the health legislation enacted earlier this year does not substantially diminish that pressure.

According to Fareed Zakaria, in his CNN special, Saving Health Care: The GPS Road Map for Saving Health Care:

The Obama health care bill expands access to 30 million Americans. That’s good economics and also the right thing to do, but it does little by way of controlling costs.There are several experiments and pilot programs in it. There are new trends emerging, but little in the way of systemic cost controls. That’s largely a failure of nerve amongst the entire political establishment.

Every expert realizes that no matter what the system of health, you will need to have some kind of board that decides that some things are covered and others are not.This has been demagogued as “death panels” when it is really the only sensible way to make the system work. No one is saying that you can’t get any procedure you want – merely that there are some that your insurance doesn’t pay for.

The other unusual aspect of health care, Kenneth Arrow points out, is that the buyers really don’t have much knowledge.You can decide that you don’t want a new car, or can comparison shop for a new TV, but you can’t decide that you don’t want a bypass.That’s why costs have come down in optional areas like LASIK surgery but not in ones where the consumer really can’t walk away.

There are powerful ways to incorporate the discipline of the market to make providers lower costs, but the key, as Atul Gawande points out, is to give doctors and hospitals an incentive to make you healthy rather than the current approach where they make money if you are unhealthy and need lots of heroic procedures.

A final thought: One can reason from first principles and that’s a good thing but you must also reason from facts on the ground. The fact is that all rich countries try to provide affordable health care for their citizens in some way or the other.

There is still much work to be done. Heath care reform isn’t an act; it’s an irreversible process.