Ladies and gentlemen, on behalf of the McClean Center for Clinical Medical Ethics and the University of Chicago's Institute of Politics, Steve Edwards and I are delighted to welcome you to today's lecture in the series on ethical issues and health care reform. Today's talk is the eighth talk co-sponsored with the Institute of Politics in this year's series. We at the McClean Center have been delighted with that arrangement and Steve tells me that the Institute of Politics has been very pleased with it also. You remember I talked to you last week about our final two talks in this series, two talks that are not advertised in the program. Next week, Jeff Goldsmith, a health care consultant from Virginia, will be speaking with us. And then the following week at the invitation of the Institute of Politics, Zeke Emanuel will be coming to campus on June 3rd. And that meeting will be at five o'clock in the afternoon at the Quad Club. I'm sorry, the meeting on June 3rd will be at six o'clock in the afternoon at the Quad Club. We understand that tickets for this event are very tight. The Quad Club is a relatively small venue. But if you want to get your name on the list of people waiting for tickets, it would be good to sign up now. Now let me turn to our speaker today, Neera Tandon. Ms. Tandon is the president of the Center for American Progress, a think tank in Washington dedicated to improving the lives of Americans through progressive ideas and actions. Ms. Tandon previously was senior advisor for health reform at DHHS, where she advised Secretary Sibelius and worked on President Obama's health reform team to develop and then to pass the Affordable Care Act. Before that, Ms. Tandon was the director of domestic policy for the Obama-Biden campaign. She had served as policy director for the 2008 Hillary Clinton presidential campaign and was associate director for domestic policy and a senior advisor to Mrs. Clinton during the Clinton administration. Ms. Tandon was recently recognized by Fortune Magazine as quote, one of the most powerful women in politics. Today Ms. Tandon will speak to us on health care reform moving forward, policy changes and cost containment strategies. Please join me in welcoming Neera Tandon. Everybody, thank you so much Dr. Sigler. I'm honored to be here and I've done a few health care talks in my time, so I always find it that I always find the most interesting part of the time is the Q&A and discussion. So I'm going to talk for a little bit, probably about half an hour about the changes in the health care system, what we're trying to accomplish, what we've seen so far. Some of this I know will be familiar, but hopefully some of it will be fresh. But I really want to hear from you and get questions and answer any questions about the Affordable Care Act because oddly enough, five years after passage, four years after passage, there are still a lot of questions. I was on the President's health care team, so I did help write the legislation, and before that I had served on President Obama's general election campaign and did a lot of work defending the law or defending the President's plan in the general election and then before that had worked for Hillary on her campaign. And I do think it was vital that we had a two-year debate on health care in the presidential campaign to get to a point where we could actually pass the law when the President became president. So this is a representation of our health care system before the Affordable Care Act. I don't think you can read the type. I can't really even read the type, but it is to denote that it has been a relatively complicated system and it really denotes the kind of challenge with reforming the health care system. I now have the privilege of working on all kinds of policy issues, energy policy, financial regulatory reform, education policy, and so one of the big challenges in health care is to reform a relatively complicated system. You have to do it in a comprehensive way because when you do one specific thing, it can have consequences on other elements of the health care system. And so that's why that's been a challenge for health care policymaking over the last several decades and one of the reasons why there was a lot of pent-up push for transformation of the health care system. Obviously, it's a big thing to take on because the health care aspect of our GDP is almost 20%. We stand out from other countries in this way. We spend a lot more on health care and I'll come back to this.  Now, a lot of people like to talk about how the Affordable Care Act transforms the entire health care system and I do want to say that while the health care portion of GDP is a large section of spending for our economy, one of the challenges with the Affordable Care Act is to build on the current health care system, make changes in the way, excuse me, we pay for health care, but for the vast majority of people, keep the health care that they like through the employer-based system. So the goals of the Affordable Care Act, as the President talked about actually way back in the general election, where it was to provide more access to health insurance. Actually getting more and more people covered was a huge part of the thing we were doing, but I really wanted to note that for the President getting health care costs down was almost as important to him. The reason why that was so critical and is so critical is that rising health care costs are a real drag on our economic growth. The United States is different from other countries. We have health care basically for the most part in the private system, it's basically run through employers, the vast majority of other countries have it directly from the government and the single-payer system because it's run through employers and employers offer health care. When health care costs go up, it's a drag on employment. So it's not only a drag on employment, but growing health care costs are a drag on the federal budgets, state budgets, and really also, as importantly, a drag on families budgets. And we had unsustainable growth from 2000 to about 2008, premiums in the United States doubled. If they doubled again, that would make it really difficult for employers to offer coverage. So that was a huge issue for the President. In our early discussions on the Affordable Care Act, the economic team, our OMB Budget Director, Peter Orszag, Larry Summers, others, Tim Gatner, were really focused on lowering health care costs. And as I'll come to you later, we've had some important progress on that issue. And finally, to have a system that's more patient-centered and less fragmented. And that's where a lot of people in this room come to come in contact with the Affordable Care Act. The goal of the Affordable Care Act was to have a system in which we basically have more value in the health care system where the patient has a better experience in the health care system and yet we pay for better care, not just more and more service. So I have to say, coming back to going through the last couple of years of the Affordable Care Act, we've definitely had some up-moments and some down-moments. Say, the rollout of the Affordable Care Act Health Exchange and healthcare.gov was definitely a low moment. But I'm pleased to talk about these numbers, which is really how the Affordable Care Act has benefited people. And the fact that we have 8 million sign-ups through the state and federal exchanges, 3 million young adults covered under their parents' plan, which has been happening over the last several years, not just this year, 4.8 million low-income adults covered through Medicaid, 10 million, close to 10 million previously uninsured individuals now covered, and 12 million predicted by CBO this year. These are real people who have tangible benefits from the Affordable Care Act. And going through the politics of this, and I don't expect the politics around the Affordable Care Act to ever entirely end, but the fact that we actually have real people benefiting, people who are working, people who, but for the Affordable Care Act, would face medical bankruptcies, a whole host of other challenges if they didn't have health insurance. You know, I think this kind of made the whole experience worth it for policymakers who've been working on this for so long. Just to specify a little bit more, we know that we are actually making real dense in the uninsured. We have the largest drop in the rate of uninsurance according to the Gallup poll in the first quarter of 2001, and these just go through the numbers again of uninsured non-elderly adults and what we expect to happen over the next several years. This is really to say that we've met some important targets. CBO had estimated that we'd have $7 million this year. We surpassed it by getting to $8 million, but there's a lot of work that still needs to be done to get more and more people covered. And the true benefits of the Affordable Care Act will really be operationalized when almost everyone is in the insurance system, and then we are taking away from some of the rising costs that we have from so many people still going to emergency rooms, et cetera. We'll have a more rationalized system if people have coverage and can regularly see a doctor, and some of the benefits of preventive care will really kick in. But again, it wasn't just the goal of the Affordable Care Act wasn't just to get more people covered, it was to have higher quality of care as well. And these are important elements that people have got lost in a lot of the headlines, but we've made some real progress on improving the quality of care. Important for hospitals, we've had really big challenges in the United States around high hospital readmission rates, and those numbers are coming down. And we've had particular benefits from lowered infection rates. This was a big push in the Affordable Care Act. Some people thought it was pretty prescriptive to essentially create a system by which hospitals would be held accountable for higher readmission rates. And it does seem to be working to create real incentives for hospitals to lower their readmission rates. And of course, when we do that, we save money. Three billion dollars have been saved on reduced hospital-acquired conditions so far. The final area that, and I'll spend probably the most time on this, because this is the area that the Center for American Progress spends the most time on, is reducing health care costs. The United States spends a lot of money in health care. 18% of GDP translates to almost $3 trillion, which translates to $8,000 per person. And we stand out across the world in spending so much money on health care. As you can see, we spend 50% more than the next most expensive country. And our outcomes really aren't so fantastic when it comes to those issues. As you know, we have lower life expectancy writ large. We obviously have some, I do want to say, being at the University of Chicago, we have amongst the best care in the world. We still do attract people from around the world to use our health care system. But when you look at our metadata, if you look at our averages across the country, and you look at both how the wealthy and the poor treated and averaged them, we have lower life expectancy. We have higher child mortality, higher maternal mortality than other countries do for the amount of money we spend. This just gives you an example of how states are allocating money and why the challenge of higher health care costs is one that can really translate to state budgets. Medicaid expenditures have been going up, while other things have been going down because health care is consuming more and more of the budget. And again, this is one of the reasons why the President took on health care. I get asked this all the time, why did the President decide to do health care in the beginning of his term? There are so many other easy things to do. And I would say that, you know, honestly, I had the experience of working for, as was said in my bio, work for Hillary Clinton in the primary. I came over to work for President, then Senator Obama would be President Obama in the general election. And our first, my second day there, we had a meeting about the issues that had come up in the general election. And a lot of his advisors had said, you know, maybe we should move on health care. It was a really important issue for Democratic voters. Not as important issue maybe in the general election. McCain will attack us a lot. But the President was really forceful. Senator Obama was really forceful. He said, if I win, I want to pass health care reform because we haven't done that. It's a huge issue. We talked about it for a year in the campaign. I made a promise I would do it and I want to keep that promise. And if I keep that promise, to keep that promise, I'm going to have to campaign on it. So he spent a lot of time talking about health care in the general election. And he wanted to do it because costs have been rising for a long time and no one was paying attention in Washington. And it was eating more and more of the budget and it would just not be sustainable. And it is a tragedy that we spend so much and had such a high uninsurance rate in the country. And both of those forces together, I think, were central reasons for him. Now, we do have some very good news on lowered health care costs. Health care is going down. We've had the lowest rate of growth in health care costs in the last couple of years ever recorded in history. I mean, we've only been recording it for 50 years. But in our time, you see dramatic slowdown. Now, I want to be clear that there's a variety of factors there. It's in part because of the economy. But I also think, and a lot of health care experts believe, it's also because of the Affordable Care Act. But this really means that as we go forward in the Affordable Care Act, it is vital that we keep these health care costs down. Because they are too high of a burden. You see, this just tells you how much post-ACA we've had rates of growth. And across private insurance, Medicare and Medicaid, they are all coming down post the passage of the Affordable Care Act. So just a few ideas about how we have lowered health care costs. And then I'll get into how we can continue. And I want to say CAP is a progressive think tank. But after the Affordable Care Act passed, we focused most of our energy on lowering health care costs. You're going to have Zeke Emanuel here in a few weeks. And Zeke is a senior fellow at CAP. And I worked with Zeke on passage of the Affordable Care Act. And Zeke's focus was very much specifically on health care cost reduction in the Affordable Care Act legislative process and since. Because it's really a system in which we're paying so much will be unsustainable. So if we care about having access over the long term, and we care about economic growth and competitiveness, these are all reasons for us to focus on it. The most important issues here is really how to pay for health care, changing the way we pay for health care, and creating marketplaces where competition itself works. And so the way that works is... Oh, I'll move to this slide. We had some increased cost in the last couple of... It seems like in the last year or so. Now, we have to make sure that this could just be because we've expanded so much coverage. This is something we definitely need to monitor. A variety of experts think that it will continue to go up, but we're hoping that through policy we can keep the numbers down. So some of the ideas in this space is writ large moving away from how we pay for health care from a fee-for-service model. So as everyone knows in this room that you get mostly reimbursed in the Medicare system and your private health insurance. Every time you go to the doctor, the doctor gets reimbursed. Every time there's a test, the test gets paid for. It's the baseline of the fee-for-service model. We believe we need to change the way we pay for health care, bundled payments, accountable care organizations, patient-centered medical homes are ways to do that. A bundle payment, I'll just use that as an example as you pay for an episode of care.  The insurance will pay for the entirety of that episode. And if the hospital or doctor saves money in the process, they will share some of the savings, it will incentivize folks not to overtreat. One of the things that we're particularly focused on, and I think these are new ways to think about how to lower health care costs, are the exchanges. The exchanges themselves will be a way in which states and the federal exchanges can use to leverage lower costs. And what do I mean by that? In Illinois, 250,000 people enrolled, hopefully those numbers will grow. That is a pretty big market. And so if the insurance exchanges use that pool of people, the exchange itself to negotiate lower prices, that will also create incentives for private insurers to use those, to follow along to lower prices as well. We hope we'll get more price transparency, exchanges will push for price transparency, and then tiered networks. Tiered networks is a way in which you have kind of options for paying more for a greater list of doctors. I will say there's a lot of blowback around this issue right now, a lot in New Hampshire, because the networks are so small and a lot of doctors aren't in them. So we have to get a right balance, because we don't want to have a system in which doctors are excluded for any arbitrary reasons. As we go forward, we've put forward a few ideas to lower health care costs. Comparative effectiveness research was part of the Affordable Care Act. It hasn't been working very effectively. Comparative effectiveness research really is a means by which we learn between two drugs, which one's more effective, between a drug or a surgery, which one is more effective. We don't have a very good means right now of understanding that, because there are not very many incentives in the system for people to figure out what's the lowest cost. With the highest value effect. And so there was something set up called the Patient-Centered Outcomes Research Institute. Something rolls right off the tongue, PCORI. That's the beauty of health care. There are so many acronyms that, like, it's hard to keep track. And that's something that so far hasn't been working very effectively, but CAP and others are really pushing to make it more effective. We need to ensure future providers are equipped to work in the evolving delivery system, in the system that's going to come up. And this is a huge issue for doctors, nurses. The health care system needs to transform itself and needs to move from this old model to a new model. And that not only means changing the way we do reimbursements, but it actually means changing the way doctors, nurses, providers are delivering care. And we want that system to be one that's most focused on getting the patient healthy and driving towards that model. And I know everyone in this room is really trying to do that every day, but we need more incentives that drive towards that value. And that's going to mean some changes in the way people are held really more accountable for the health of the patient versus just having a system where doctors, nurses, et cetera are providing some care and then getting reimbursed for that care. We want a major system where there's a point where someone is really in charge of moving a sick person to health. And that's a system many parts of the country have moved to already, but we need the entire system to move in that direction. And as we move forward with the Affordable Care Act, it's a very complicated bill. There's a lot of elements to it. Things like free preventive care. We need to get more and more of the word out around those issues so that the benefits of better prevention can be realized. And with that, I hope we can take some questions. I usually find the questions are much more interesting than the presentation, so I will look forward to that. Thank you. Thank you so much. I'll start with the first question. And that is, as you were working on the campaign and deciding that health care reform would be one of the priorities and early in the administrative program, did you anticipate this amount of political problems going forward? So the short answer is no. I mean, we anticipated political problems and polarization, but not this level of opposition. I'd say, I mean, there's a level of opposition that's been created in the last few years that's different from, not just in the Affordable Care Act, it's writ large, that's different from anything we experienced, say, in the 1990s. And that wasn't like a moment of kumbaya every day, either. But as I would tell, I mean, I would tell my Clinton alumni friends it's much tougher in Washington than it was back then. So, I mean, the evolution of what really actually happened is that we had the, we were going through the legislative process really early on. And in fact, in March of 2009, the president had a White House summit on healthcare in which, you know, Mitch McConnell came to the White House. It was bipartisan House and Senate leadership. And, you know, they were talking about the cost being too high and not wanting a single payer option, a public option, sorry. But it was, it wasn't, there was not a debate about whether we'd pass a bill. There was a debate about what kind of bill we'd pass. And then in June of that year, Frank Luntz did a memo for everybody basically saying, you know, we have to stop the bill. It'll be, it's our ticket to come in, winning the House and Senate back. And Frank Luntz, who's a famous GOP pollster and more strategist who does a lot with wording. And he, you know, he sort of started talking about death panels, et cetera. And that's when it really polarized. You know, to me it's kind of an extraordinary moment. The extraordinary moment has really come, though, in the passage of the bill. Because, you know, throughout our history, once a bill gets passed, people work to make it better or, and there are definitely ways to make it better, make it better or to tweak it. But the whole tragedy of the Medicaid system where we now have a system that in many states, you know, there's kind of this gaping hole and if you're middle class or lower middle class, you have coverage. But if you're below that number, you don't have any coverage unless you're in Medicaid. So, you know, sort of the most deserving, which is lower income working poor folks, not getting Medicaid coverage because the governor hates Obamacare, even though it's huge reimbursement to the state. That I think is kind of unprecedented level of, you know, almost vitriol. Versus, you know, anything, any level of obstruction. And we, we, I can honestly say no one anticipated that, that level. Thank you very much for allowing us much time for questions. I appreciate it. Sure. I wanted to ask, first, when Dr. Siegler introduced you, he described the Center for American Progress as an institution that works to find progressive solutions for Americans. And I wonder how as a representative of that institution, that organization, you can be supporting an act that is very non-progressive, let me say. It seems, again, let me, let's talk about one dimension on which I think it's very non-progressive, this act that was created by the insurance industry for the benefit of the insurance industry. If you have a... Let me ask the question, please. Please. If you have a four-tiered system, that you've got the bronze, silver, gold, platinum, it seems to me that, isn't it true that most people who are not fairly well off are going to tend towards the lower tiers of that system, which means they're going to be responsible for something like 40% of their medical bills. That is more than enough, isn't it, to put people into bankruptcy. So how do you see this as progressive? Why aren't you instead supporting a single-payer system? So, I think I would say to you that we've worked on healthcare for 70 years, 80 years. We haven't had a single-payer system. We have 8 million people covered today through the private exchanges that didn't have health insurance before. And for each of those 8 million people who have health insurance, you didn't have it before the Affordable Care Act. I would say to you, it is better to have health insurance today than to wait for whatever date you believe we were going to get a single-payer system. I would say, myself personally, if you look at other countries, they have good healthcare systems through single-payer. I'm not in opposition to single-payer system. But having gone through what one could argue is a very difficult process to get the Affordable Care Act, the idea that we were going to pass single-payer anytime soon is very optimistic in my assessment. And in my view, and a view of a lot of progressives who fought very hard for the Affordable Care Act, including Ted Kennedy, until his dying day, doing something for people today versus waiting forever for our ideological beliefs was not what a real progressive does. A real progressive tries to make positive change where you can to improve the lives of people who need it. And so I don't apologize for supporting the Affordable Care Act. And I will say that the vast majority of folks are actually getting the silver plan. They're not picking the browns plan. Even low-income folks are picking the silver plan. I think I had a question about the cost piece of this because many analysts who have in fact been in the dark months of legislation can see that while this bill does it, this legislation does a tremendous job of expanding the coverage pool, the cost questions are still open once. So in the midst of possibilities, the midst of strategies that this law allows you to try, where do you see the best progress coming in reducing costs over time? So cost is a really tough issue because if you look at the national numbers, costs are coming down. The challenge is people feel like costs are going up, right? Because we have had a 12-year, I mean since 2000 we've had rising out-of-pocket costs for people, like a good example is deductibles. In 2000, very few people had to pay a deductible over $500. Now that's 70% of people have a relatively large deductible, $250 or above. So people are actually experiencing greater costs because employers are shifting costs. In order to deal with the burdens of premiums, they're shifting costs to individuals. So the cost issue is front and center in a lot of people's minds. And to me, I think there's really two areas of opportunity. One is moving, I'm a big fan of bundle payments. Other people will have greater expertise in this room about how effective these programs are. But I think moving to a system where you're actually paid for the episode of care will help create incentives for less volume. We have to be careful, though, and I want to say policy is about the details. You have to be careful that the bundle payments take into account how sick a person is, et cetera. So they're right incentives in the system. But I also think going forward what particular states, California is a great example. They use active purchasing. So they really use the power of their market to negotiate prices really effectively. And one of the reasons why California premiums have been lower is because now they have a large market, a large group in the system in California, which is really pushing prices down and private insurers are following. So I think that that is a good opportunity. The truth is none of the stuff is sexy or as interesting as death panels, or I should just be clear, the lack thereof of death panels. But I think this is really important to get right over the long term. Thanks for being here today. I certainly thought the group away from feedback service. Right now you're on more of the education side of things. You're also seeing kind of on the fringes and startups around cost transparency and some insurance demands going forward is more high about both demands. How to see maybe the success of that kind of side of the industry and what to do from a policy perspective maybe to research that. I'm sorry, before you said price to insurance, you said with patience at the fringes you're seeing. I'm sorry, I just didn't hear what you said. Yeah, just there's certain sort of like cast lights. Startups, yeah. Just to increase the ability to patient function what the real costs are. Yeah, so that's a great example. Cast light is a system that's basically trying to make it much more transparent what hospitals are paying for, what you're paying for in your premiums and in your costs. And we are a strong supporter of transparency. This issue I talked about a minute ago of costs going up and cost shifting is a double-edged sword. So because you have high deductibles, there is some evidence people are using the health care system less. On the other hand, it's also the true that people are getting less preventive care because they have high deductibles that they're anxious about. So it's really hard to navigate. I think when you have a $1,000 or $2,000 or $3,000 deductible, that's a lot of cost. And I agree in the Affordable Care Act we want to move in a system where there's some skin of the game but people aren't so burdened that they're not using the insurance that they have. So it shouldn't just be catastrophic, it shouldn't really just be catastrophic health insurance. You should get some help for when you use health insurance regularly. So I think there's a variety of issues. You should probably have deductibles, not huge deductibles. We should have greater transparency in the system. There's a lot of fighting about that. Hospitals right now still have a lot of uncompensated care. So their argument for some of the costs, some of the difficulty with transparency is that they have to cost shift to take care of that and it's unfair to burden them with that. If it's totally transparent, then people will think I'm getting really burdened. You're getting benefits from your experience with the health care system. So these are important issues. We push a lot on transparency and I think we are getting more and more and more of it and hopefully with the advance of technology you'll see much more use in the coming years. You mentioned that it's difficult to have public perception experience and perception with that. I'm happy to talk about that all day. I think of health care cost issues. This is really such a tragedy from the polarization because if you actually think about, for most of the late 90s through the 2000s, it was moderate and conservative health economists who really focused on issues like getting more efficiencies in the health care system and lowering health care costs. Mark McClellan is one of them, but there was a whole range of substantive, serious thinkers and they did a lot of work in the Senate. The truth is that comparative effectiveness research was something that was very bipartisan. I think probably more conservative-supported compared to effectiveness research than progressives really. It's been a lot of progressives in the past who've raised concerns about high deductibles and things like that. I remember I was on President Obama's transition and Mike Enzi who was then ranking in the health committee. We looked at everyone's record. He was a huge supporter of comparative effectiveness research. Then when we went through the process, there was a political argument made that you could translate health care cost reduction to rationing, health care rationing. The truth of it was all these people who've been really concerned about health care cost reductions a minute ago started hitting us on rationing health care through the precise means they had championed a year ago, a year previously. I believe consistency can be the hobgoblin of little minds, but that was a little much. I think that my experience with the Affordable Care Act, which is I still have the scars to show. I went through it and my PTSD from the experience ended just about a month ago, but really at the end of the day, you kind of have to do the right thing. The truth is you're going to have to live with the law. We're going to live with this law. People ask me all the time about why Obama did it, and no one was thinking. Susan was there, too, at the time, but I certainly wasn't going through this experience thinking this was going to help us politically. The President did it because he thought it was the right thing to do. Believe me, he had a ton of advisors all throughout willing to do something else instead of healthcare. This is a cynical age, and people think the worst about politicians, but the Affordable Care Act was an experience where the President really was trying to do the right thing and thought it was the right thing to do for the country. Members of Congress, some of them were kind of lame, I will admit, but most of them, we were going in there and telling them they wanted to know what the bill would do and they basically wanted to do the right thing. There was all these side shows, but the vast majority of the interactions on that bill were about how it would work and what it would do for people. We have a challenge in a media environment where it's much easier for reporters to report on a cornhusker deal that's actually not in the legislation itself. Versus reporting on what an exchange is, which is the heart of the legislation. We're not going to change that game. You have to just live in the game that you're in. But at the end of the day, I honestly think people were trying to do a very difficult thing to reorient a significant change at a time where people have deep skepticism about government and its ability to act, and we faced a lot of headwinds, but the goal was really to fix this problem that we are unlike almost any other country in our inability to fix it in the 21st century until today. I'd love to have you say a little bit more from an insider's point of view about the death panels. I ask that because this series next year, for those of you who might be around and interested in coming, we'll be on end-of-life care. And the McLean Center, I hope with the involvement of the Institute of Politics, we'll be supporting again as this year, about 25 or so talks on Wednesdays on end-of-life care. I mentioned that to Nira on our way into the lecture today, and asked her if she would say something from an inside perspective about the death panel problem. So on end-of-life care, it's obviously a huge issue in the healthcare system. A lot of costs at the last couple of months of life. I think it's like 30% of costs at the last three months and even higher in the last six months. So from a policy perspective, people are relatively interested in how to deal with that challenge. We had something in the House version of the bill, which I will literally describe it as, if a doctor tells you about alternatives, alternative end-of-life issues, and not prescribing anything, just tells you about them, hospice care, other things. Just the availability of alternative end-of-life options for you. That doctor would get reimbursed for telling you that in the Medicare program. And that is what became the death panel praise. That was literally what Sarah Palin was saying, was going to create death mills. Honestly, I think she did get confused between comparative effectiveness research, which is a whole other attack, and this one, but I remember it so vividly, it was like the crazy wingnet blogs had it, on like a Thursday. And by Wednesday of the next week, it was in a Robert Perry story in the New York Times. And, you know, he protected himself by saying there is an accusation, but once you have it listed as there is an accusation in the New York Times, there's like full sanction for going whole hog on it. So, you know, this is the, again, I probably could spend every topic I discuss going after the media, but I don't want to do that. This is a huge challenge in a, he said, she said world of media coverage.  And then, like, what do you have in your mind? A death panel, right?  So, I mean, in any complicated public policy issue, it's really easy. And, you know, I'm not saying only one side does that, you know, kind of attacks the motives of the other side or makes crazy accusations. But it is, I mean, one of the hardest things about the Affordable Care Act is it's a complicated policy as demonstrated by my wonky talk about it. It's not easy to describe or communicate. And what was kind of the most disheartening thing to me about it was, went through this full year of a legislative process. And people's, and, you know, there's coverage of elements of it almost every day in the press. And then if you did public polling or public research or research on people's understanding of the Affordable Care Act, everyone could understand.  But nobody knew what an exchange was or what the Medicaid expansion was or that people didn't even understand that you were going to get subsidies for coverage. They just thought there was a mandate to get insurance and no one was going to help you buy it. I mean, it was just, like, the most basic information. And, you know, I just think people kind of fell down on the jab because it's not interesting. You know, health exchanges aren't sexy until they're not working, right? So it's really a tough issue to make public policy. You know, it's one of the reasons why it's harder to make change today than it was, like, say, 50 years ago. But that doesn't mean we shouldn't try. I want to reiterate the point that Ms. Tanden just made. And that is, you saw from the slides that the U.S. health system is a $3 trillion operation consuming 18 percent. And it's not clear that it's going to stop at 80 percent. Right. And this end-of-life question becomes really a major political matter as you think of perhaps a third, maybe even more than a third, of healthcare expenditures being utilized in the last three to six months. To give you an idea of what $3 trillion is, when I checked a few years ago, there were only six economies in the world. I'm talking now about Japan and Germany, the old Soviet Union, but not modern Russia. Japan, Germany, only six economies in the world that cost more than the U.S. health system. Yeah. That's, I mean, it's a staggering thing. We compete each year for 6.7 with Italy, for example, which is bigger, the U.S. health system or Italy. So this end-of-life matter is really a major political problem. And let me just say one final word about that. You know, having gone through it, the issue that, you know, again, I have the privilege of working now on a whole host of issues and used to work on a whole host of issues as well. And healthcare is very different than every other issue. I mean, that's the benefit and cost of working on healthcare policy is, you know, unlike financial regulatory reform or foreign policy in any way or energy policy, almost every person feels like a healthcare expert because they have some interaction with the healthcare system. And it's not just an interaction.  These are how you interact with the healthcare system. So the challenge from a policy perspective is people are very anxious about healthcare and can get very scared about it. And that's, I think, what happened with death panels. There was an opportunity to make people really scared about this big, crazy thing that could happen to you and people took it. And, you know, I don't think you could do death panels for financial regulatory reform in the same way. But I do think it makes it very challenging to tackle from a public policy perspective this challenge. And that's why I think it's really important to have also private sector efforts to inform consumers. The truth is, consumers want information about end-of-life options. So I just wanted to say that. I want to thank you for your presentation and also for the work of the Affordable Care Act to come along despite all the challenges. I live in urban Kentucky. Kentucky is a success story. Yeah, fantastic. We reviewed some of those, in the beginning to make a real inroads in eastern Kentucky by 40 percent. I know. That's a staggering number. And I think it's testament to the courage of the Democratic government and the state of red states to support it. Last night, Alison London-Grimes, who's challenging Mr. McConnell this fall for the U.S. Tennessee, gave a fiery, very well-educated, post-election victory speech. And she articulated all her political positions in which Mr. McConnell is quite vulnerable. And she's got a real shot at winning. She didn't say a word about the Affordable Care Act. It's a success story. And my question to you is, why are not Democrats in states like Kentucky running on the Affordable Care Act? My second question is, if your own boss runs for president, will she run on the Affordable Care Act? You know, I have to say, you guys are really slowing down on the jab here because usually that's my first question. And it usually comes not in, and if she runs, will she run on the Affordable Care Act, but is she running? So I appreciate the health care related on to right into that. You know, we actually had President Clinton at CAP last week. We have an annual Gala, which we're very honored to have him speak at. And at that Gala, he made the point that Democrats wherever there are should run on the Affordable Care Act benefits. And you know, my, I have worked in policy and I have worked in campaigns and my view of this is that people smell fear. And when you refuse to talk about something that everyone sees and knows in the room is there, people can sense that they'll just think it's a terrible thing and they'll think it's a worse thing than if you had bothered to defend it. Now, there's been, I think there was a research that came out last week that shows it was like there's been $400 million spent on the Affordable Care Act, 90% of it negative, only 10% of it positive. So, you know, it has a negative aura in states that have done a great job. And I want to, I have to single out Steve Beshear, Governor of Kentucky who has done a phenomenal job. Jerry Brown has done a phenomenal job and Steve Beshear has been in a sea of red. Senator Beebe has done a great job in Arkansas as well, but Kentucky's numbers are really a model for the nation. I mean, they've literally halved their uninsurance rate which is quite an amazing success.  I do hope she wins, but I'm still to see that I would take a different course. And, you know, we talk about I think it's not a problem to talk about the benefits to the law and things that need to be fixed going forward. And health care costs are an area that I think everyone sees as something that needs to be fixed. But I agree with President Clinton on this one until I hear you. And on Hillary on health care, I will just note that the law did have an individual mandate like she had her plan in 2007, but I've now gotten over that primary.  And I mean, I actually expect her to talk about the Affordable Care Act, things that should be fixed going forward to make it better, but that, you know, this is a huge achievement that this country hasn't been able to do. And she, you know, she worked her heart out and failed and recognized every day how important it was to have success. So I imagine she would be doing if she runs. I see a lot of hands still up. About the problems we are having regarding contraceptive coverage. contraceptive coverage. I mean, what's happened with contraceptive coverage is that the Affordable Care Act had preventive benefits specified that there would be no reimbursement, full reimbursement, no cost for preventive benefits. And then the Institute of Medicine and it was let in the bill was said the Institute of Medicine, which was a group of medical experts would decide what preventive benefits, how to define preventive benefits. And it was the Institute of Medicine that said contraception was a medical would be is a preventive benefit that should that should be covered. So I had the great misfortune of actually working on the abortion language in the Affordable Care Act but the issue around contraception wasn't litigated in the Affordable Care Act itself and wouldn't have been wouldn't have been I don't think it would have been different if we had a public option or a private option because either way employers would be just to be clear on contraception contraception issue isn't a debate just in the exchanges the contraception issue is everybody now gets free access to preventive benefits like contraception so people who have been providing healthcare all along now are getting this reimburse so it's not really a public option issue but you know I think the fact that we're litigating contraception is kind of a ridiculous thing and I hope the Supreme Court does not create a large curve out for private companies to not offer this insurance in what they're privately doing we talked about whether Democrats should be running on ACA and I actually have a question about the office which is where it's no secret that Republicans are vehemently running against ACA so my question is how far back do you think we can go what's the worst case scenario about how many people work and the conversion of that what do you think is the strongest next step that we can do to maybe address some of the concerns on that side so that we can keep moving forward you know I'm always an optimist so the last two you know we got 8 million people covered in the last two weeks it's like the first time and since the Republicans took over the house there hasn't been a hearing on healthcare or some kind of investigation of healthcare so and the truth is that they are having a little bit of difficulty now describing you know there is more pressure on Republicans to say what they would do to replace it some Republicans just was in New Hampshire and said he wanted to repeal it and then also said fixes he wanted and they asked him well do you want to repeal it or fix it and he got all confused I won't say anything about Scott Brown but but so I think the most important thing for the lot to do is to succeed and to keep covering people because it will be harder and harder for people to undo it and I think it will be very my view at this point is it will be near impossible for Republicans to take away I mean let's say they magically won the president they could win the president presidency take the house and senate at that point we should be at 15, 16, 17 million people covered through the exchange they would have to come up with an alternative and what I said at the beginning is the truth about healthcare it's hard to come up with just a fix here and a fix there you know the reason why they haven't been able to come up with an alternative to just fix the things they think are egregious is that that usually drives costs up or drops coverage from the employer based system or does something else a great example is there's been all this complaint about the Affordable Care Act and the 40 hour work week and whether employers are dropping because of the restrictions on the Affordable Care Act around having to be full time and what that means and the Republicans put forward a bill to fix just that problem and it had 18 billion dollars of cost and would have dropped a million people out of their employer based health insurance system by doing that so you know it's not an easy it's not an easy thing and one of the reasons why they put forward a replacement I think is because it's difficult to do so just getting more and more people covered I hope means that we'll be able to I love that first slide you showed which was the pre-system before the Affordable Care Act it wasn't so clean and then nobody could read it but it was very simple way back, yes thank you for coming it's great to learn about ACA and what it has to offer principles about the value basically the Affordable Care Act trying to find the dollars that are out there instead of doing them to just trying to find the value over a dollar speaking of the New York Times three days ago there was an article that was published that highlighted the amount of compensation that was given to CEOs of major insurance companies I'm not sure if you had chance to admit it but I mean we're not going to their salaries are about $27,000 but they're a total compensation of the year is $20,000 so I'm learning that if you go into legislation or any kind of eyeball that's being put on the back not only for the health care workers in general but also for the patients to see that value of the dollars instead of going into that pocket at the spread of costs yeah so you know CEO compensation in the US is far out of whack with other countries I mean our lowest CEOs are paid generally 10% more than the highest paid CEOs in Europe so we have a challenge with CEO compensation at large and I think we do have a challenge which is that insurers have been and will continue to be relatively profitable and one of the things in the law was medical loss ratio which is a fancy way of saying that 85% of the premium actually that you pay actually has to go to delivering health care versus profits of the health care system so that is creating some downward pressure on payments insurance fluff but there's definitely more we can do now my view is the Affordable Care Act allows states to have a public option Vermont is going to move to a single payer option I think it's a tragedy states like Illinois pretty progressive state it should have a public option to create some of the pressure on insurance companies I fought on the public option in the legislation I think a public option should have been in the legislation because it would create some of this pressure between the public and private sector there are additional legislation on price transparency which is giving states the ability to better regulate premiums themselves and push when premiums go up a certain amount more than 5% ask for where more clarity on things like where the money is getting distributed with the insurance companies I think those are really good ideas and I think the truth is as more and more people face higher deductibles and high premiums there should be more pressure in the system and there should be on how the money is getting allocated between insurance companies and their providers as well that have a lot of high pay are you basically asking a single payer more efficient no the US heterogeneous population heterogeneous got it McKinsey did a great study about seven or eight years ago on US health care spending versus other countries we are different on a whole host of issues I don't want to say it's because we are more heterogeneous and other countries are more homogenous there are countries that no country really approaches our level of heterogeneity and they still have really low health care costs and it's a variety of things that contribute to it just having a culture of walking and not driving, having things much closer together, having a single payer system which invests much more in prevention because you have one payer who is going to be there for the life of you versus several insurers so there is a much bigger incentive to pay for things like high preventive benefits etc there is a whole variety of things and I don't think anyone has really figured out the specific reason why we are so terrible but we are pretty terrible that's a great reason for people to continue to invest and study this area and provide us great things about being in an academic institution is that you can provide us answers to policy questions like this please join me in thanking your tenant for wonderful work thank you so much


Hello everybody, Andrea Maeski here with Dental L. So day in the life of a mobile hygiene practice owner. So I'm just gonna talk about it cause I wish I had somebody to follow me around with a camera, but I don't at the time. So how do I set up, how do I prepare for my day? How do I book patients? So overall, I see about two households per day. Two or three if I'm that busy. And I try to go to one city per day. Or you know, so then that way I'm not going to one city and then having to travel half an hour out of the way to see the next house. So I will only see patients in the same area per day. It was tricky to do that when I first started my practice cause I just wanted to get in patients. So I was going all over the place, but now thankfully I am able to do that. For example, I was in Woodstock yesterday. Tomorrow I am traveling here in town in St. Thomas. The next day I'm going to New Hamburg. So you know, I try to see people in the same area per day. So I see two or three households at the most. The amount of people that I see per household will obviously depend on how many houses I go to. So I do try to have the day go from like nine to four. So then that way I am home by five o'clock every day cause it's just nice to not have to work too much, right? And mobile hygiene is hard because you have to lift everything in the car, out of the car, into patients' homes, sometimes up steps, down steps. So that's the hardest part. I'm used to it now, but when I first started I would be doing all of that. And then I would be tired by lugging in all of that stuff and then I'd have to clean somebody's teeth. So it was hard, but you get used to it. And that's probably why a lot of people don't continue to do mobile hygiene because it is hard and they don't push through it until they get used to it, right? I just lost my train of thought. I was going to say, I was talking about how many people I see in a day. We talked about that, oh, okay. So let's talk about timing. So if I'm seeing one adult patient, I book two hours, one hour for the cleaning and then one hour after that. So it takes me about 20 minutes to set everything up and then 20 minutes to tear everything down. So one hour for the cleaning plus 40 minutes total for tear down and set up, that's almost two hours. So per person I book two hours. If I'm seeing, for example, two adults in one household then I will book three hours because I need the one hour for the one adult, another hour for the other and then I do always account for the hour total of 20 minutes to tear down time, 20 minutes set up time. So yes, that's only 40 minutes but I like to have the extra 20 for just whatever, right? So you might be wondering, well, if you're seeing two different houses how do you plan your time that way? Plus you need a break. When I first started my practice I kind of forgot to schedule a break for myself. So I would be at one house, seeing a couple of patients and then I'd have to go to the other house and I would have like 20 minutes to spare. Even if the next house is 10 minutes away I'm only allowing myself a 10 minute break. Well, I kind of need more than that, right? Plus you should be taking notes after every patient. So I've changed things a little bit. So now what I do is I book an hour extra for my lunch time, okay? And that does help so much. So if I'm done a little bit early, that's okay. Then I have a little bit longer. If I'm a little bit late then I might get 45 minutes further lunchtime but that's okay. So make sure to book and lunch for yourself. Plus I take my laptop with me everywhere. I have my dental hygiene software on my laptop. So after I see a patient I do write all of my notes in the car. The best thing ever is get a recorder because that's what I do when I'm at somebody's house for charting because I don't have an assistant. So I will turn that on. Chart the odonogram, do the new patient exam, talk about anything. And then I listen to that in the car and then do all of my notes on my laptop. So that really helps. I didn't have a recorder initially but because I thought that I would just remember things but you don't, you forget. So that helps so much. A lot of people ask me, well, doesn't it feel weird like going to people's houses? You don't know who they are. You get used to it. I just say hi, I am here to clean your teeth today and that's just how it is. I do have every single patient fill out a medical history online before I see them though. So then that way I do have an idea of what I'm walking into. Has it been 10 years since their last cleaning? Has it been six months? Do they have insurance? Do they want me to put things through to their insurance first? Is cost a concern? Things you like to know. I see a lot of patients that are very, very anxious. So that is good to know beforehand, right?  You might talk a little bit more. You try to make the patient comfortable. So I have them fill out the forms first before I see them. And then that way too, before I see them, if they want me to submit to their insurance company, they have to call their insurance to get all of that info. I do not do that because I'm doing them a favor. That's how I see it, by having them only have to pay the difference. I don't have time and I don't have an assistant. I don't have a receptionist to do all of that work. So I do tell them it's their policy plus I do tell them with the privacy laws now, insurance doesn't tell me a lot. So even if I did call them, they might tell me info. They may or may not. So it is up to them to call, to ask the percentage that they are covered for and to check to make sure that they are covered for a re-care, a scale, a polish, and a fluoride if needed. And that's it. So I have them do the hard work, which isn't hard for them because they should have all of that info anyway beforehand. So then that way they are fully aware. Afterwards, I do follow up with all of my patients that night, just to make sure that they are doing okay, if they have any questions, if they're sore, sensitive, anything. So I make sure to do the follow up. And I do book their next appointment that day because that helps me build my practice. When I have appointments, when I have people, that helps, right? So I don't wait for them to book. I book it that day for their next one. It would just be so much nicer if somebody could follow me around with a camera, right? So that way I can show you guys how it actually works. But if you guys have any questions, let me know. I am so happy to help. I do have my at home practice too, as you guys can see. But I will do another video on that maybe a little bit later. So thank you guys so much for watching. If you need anything, let me know. And have a very good day.


In other news tonight, attorneys for a Minnesota man sentenced to death for killing a University of North Dakota student in 2003, are raising questions about evidence presented at trial that the student was raped. Alfonso Rodriguez Jr. of Crookston, Minnesota is appealing his conviction and sentence for kidnapping and killing Drew Shedin of Pequot Lakes. In a court filing Tuesday, Rodriguez's attorney argued that lab tests show that a medical examiner was plainly and indisputedly incorrect in testifying Shedin was raped. The defense attorneys want to question the prosecutors who handled the case to determine whether they knew or should have known the testimony was flawed. If you've enjoyed this segment of Lakeland News, please consider making a tax-deductible contribution to Lakeland Public Television.


Hi, this is Pete Chadwick. I'm from Sousa. I'm here on behalf of the Product Working Group of the Outlook Staff Foundation and today I'm talking with Ben Schwartzlander who is the PTL for the Manila project which is shared files as a service and we're here talking today to Ben about what's going on with Ella and Newton.  Okay, hi I'm Ben Schwartzlander. I'm the project team lead for Manila basically from the beginning of the project until now the Newton release cycle. I work for a net app in RTP North Carolina and I'm a principal engineer as well as an open stack architect. Okay and what are some of the highlights of the things that you have that you have been working on as part of Manila for, well first of all why don't you start off by telling people a little bit more about exactly what Manila does. Sure, so Manila was created to add shared file system storage to OpenStack. It's analogous to the Cinder project but it provides NFS exports, SIF shares and other shared file systems instead of block storage. So it's a compliment to Cinder in terms of storage. And what were the, at the recent Austin summit and through the various meetings you've been having, what are the hot topics that your team was trying to address at the design summit and sort of what are the outcomes of those, were those topics, of those discussions? Yeah, so I would say the main topic in Austin was discussing what it's going to take to get some of our currently experimental features to be officially supported. For example, we have shared replication and shared migration are both currently implemented in the Mitaka release as experimental features and we'd like to get them to be generally available. So the thing that we focused on was what are the gaps that we have to address before we can officially support these features. For example, shared replication doesn't yet support secure multi-tenant configurations where we use shared servers and shared networks. It currently only works in a no-share servers driver mode and the shared migration doesn't currently support any optimized migration path. We don't have any back ends that have implemented that. So that's something that we need to implement and test in the Newton release. We hope to address both of these gaps and get those features to be generally available within the Newton timeframe. And from an end user perspective, what kind of problems will those features help address? So the shared replication addresses sort of a disaster recovery use case which we hear everyone talks about. In fact, there are several new projects focusing on the disaster recovery area. So, shared replication is specifically designed to make it possible for end users to control the replication of their data and to control the high availability of their data to protect themselves against outages, even outages of an entire availability zone. Replication protects you against that. Shared migration has all kinds of applications. The initial implementation is just the basic support for administrators to move shares around from one storage controller to another. But in the long run, we hope to provide an end user facing interface on top of shared migration to allow people to do retyping, migration between availability zones, migration between data protocols perhaps. There's all kinds of changes users may want to perform on their data that all boil down to migrations internally. Okay. What would you say the top three priorities for new features and enhancements look like? Yeah, so as I mentioned, from what we discussed in Austin, the top priority is to complete all the experimental features. We don't want to have work that's half done and not implemented, so we're prioritizing completing things that have already been started over starting new things. There is one new feature, which is really compelling, which was proposed by Mark Koder, the Hierarchical Port Binding Work, which will allow back ends that use VLANs to segment different tenant data to plug into Neutron, even if you're using VXLANs on the Neutron side. That's really exciting to be able to bring that to Manila so that you can actually stitch your share networks into your Neutron network seamlessly, even with back ends that don't natively support VXLANs. Test coverage and improving and maintaining quality is very important to us. In fact, we're developing a new container-based driver specifically to help us improve our automated test coverage of share servers and secure multi-tenancy. We're increasing the scope of our scenario tests and increasing the scope of our third-party CI requirements to ensure that we maintain a high level of quality. Okay, so would you say the themes were on stability and manageability for the most part, was where you're focused right now? Well, yeah, I guess it depends on how you look at it. Stability, resiliency are related to the quality that we're trying to drive. We are starting to lay the foundations for high availability. It's something we've wanted to do for a while and as we've looked at that feature, adding a true high availability solution for Manila itself is going to require some architectural changes that'll probably spend multiple releases. Some of that will start in Newton, but manageability is also a theme for us. Getting UI coverage for all of these new features. We've implemented new features. We don't necessarily have them showing up in the horizon interface. That's part of completing these new features and making them generally available. Getting the user interfaces implemented. Okay, so can you look forward a little bit to talk about where you think the focus is going to be during the Ocata cycle too early? Well, the theme in the past has been that we typically carry over a lot of work. As I said, we hope to wrap some things up in Newton which will hopefully leave us more bandwidth to start new things during Ocata. As I mentioned, high availability of the Manila service itself is going to require some architectural changes that will span more than just one release. So hopefully if we make enough progress during Newton, that's something that could be delivered in Ocata and we could have true availability of, you know, high availability of all of the Manila services with redundant copies and similar to what other OpenStack services have done. Okay, I guess that was kind of the wrap on specific questions I had. Is there anything else that you think that the broader OpenStack community should understand about what you're trying to do with Manila? Yeah, I guess one of the interesting things about Manila is it was probably one of the first projects to be added to OpenStack after the Big 10 theory was established. And so that means that, you know, we have integrations with projects like DevStack and Tempest and Horizon, but we're not integrated in that we're in those projects. We have plugins to those projects, unlike Nova and Cinder and some of the original OpenStack projects that are simply integrated directly with those. So we have some unique challenges in terms of how we integrate and because we're sort of farther along on these integrations than a lot of other projects, we're sort of bumping into some problems with how do we keep our tests stable as Tempest changes? How do we keep our UI from breaking as Horizon changes? We need to interact with the rest of the community and find solutions to these problems and we're looking for new contributors to join and help us address those those kinds of problems because Manila is kind of unique in our position as sort of one of the first projects to join under the Big 10. Okay. Great. Well thanks for spending the time and we'll look forward to seeing what comes out of the group over the next you know over the the rest of the Newton's pipeline and looking forward into OCOT.


Today I'd like to address a topic that's been in many people's mind lately. How does VapCap work? And more specifically, how does the air flow through it and how is the vapor produced? Let's get into the dynamics of how a VapCap functions. VapCap flow dynamics 101. The airport is not a carb. So to begin with, let's identify some of the key points on the device. The airport and for this video and for future videos and for other references is referred to the airport and not a carb because it's an airport that has a much more significant function than a carb that simply let in air to clear a chamber. The airport allows air to be introduced into this device so it can become an important part of how the device functions. As that air then enters here and travels away from the mouthpiece towards the tip where it then introduces a significant amount of turbulence as it picks up vapor that is then displaced by the small amount of air that you see traveling underneath the cap on the outside of the tip and then through the material in the extraction chamber. On the other hand, when the airport is obstructed, which obstructing the airport to some degree can be very desirable for some users under some circumstance depending on what type of experience you're looking for. So in this animation you can see all of the air flow is now being directed between the cap and the tip as it flows between the cap and the tip it is heated up by the temperature of the materials that have been heated up by your heat source. That air as it exits the space between the tip and the cap then creates a vortex and heats up the material that hasn't been heated from the conduction through the cap and is also displacing all of the vapor that's being produced by the material that's been heated up. What you'll also notice in this animation is that the vapor flow through the condenser is much much slower because there's no air flow through the airport to help accelerate it or to mix with it to cool and condition it. In addition to that what the animation doesn't show is that when you force all of the air through the extraction chamber instead of just enough air to displace the vapor that's produced the extraction chamber cools off much faster and requires a subsequent reheat and it's not that it won't work one way versus the other, it's just that the way the device was designed and engineered to function optimally is generally with the airport in a semi-unobstructed or fully unobstructed manner. When utilizing the rocker which is again opposite to the airport it allows for a very tactile way to locate this without looking at it and by rocking the device back and forth we can partially or completely obstruct the airport which then allows the user to tune the device for the air flow characteristics and the vapor experience that you're looking for. So one of the things that you're going to notice as you begin to modulate the air flow through the airport by opening it up or leaving it completely unobstructed is that you're going to get a much freer flowing experience and a much cooler conditioned vapor as well as your device will continue to produce vapor for a much longer period of time. Back to the first animation, here again when the airport is unobstructed and you can see by just simply rolling the device a few degrees between my fingers I can fully open it and I can partially close it or I can fully close it and it's very intuitive with the spine of the rocker in my thumb. This allows for that modulation of the dilution air and also the turbulence inducing and vapor conditioning air to enter the device which then allows the device to function in a much more fully flowing manner as well as enabling the device to continue producing vapor for a longer period of time as we're not forcing as much air through the cap and through the tip accelerating the cool down of the little bit of thermal mass that we have. In summary, I hope this video helps explain how the airport is a very functional component of the device and is not a carb. So please give it a try and let us know what your thoughts are. Hopefully this improves your overall experience with our devices. Thanks for watching. For more videos click here or here and don't forget to subscribe.


In this video, I want to give you a short introduction to Fluendy, an open-source log-data collector. To understand what this actually means, I will first explain why we actually need logs, the challenges of collecting and consuming application logs, how Fluendy works and how it solves all those challenges, and finally how to configure Fluendy as a user. Let's say we have a microservices application deployed in a Kubernetes cluster. Two applications in Node.js, a couple of Python applications, maybe databases, a message broker and other services. All these applications talk to each other and produce log data. So each of these services is logging information about what the application is doing. Now, what are some of the information these applications are logging and why do we need this log data? This may be some compliance data, for example, like if you're required to log some specific information depending on your industry in order to be compliant. It could be for your application security, for example, to detect suspicious requests in your application by logging all access attempts with IP address and user ID, etc. or log with accessing what and when. And an obvious usage for log data is debugging your application when there is an error, analyzing all application logs to find the cause. These are some of the examples why log data is so important. Now, the question is, how do applications log this data? There are a few options. First one is applications right to a file, which is a common way of logging in applications. However, as you can imagine, it's difficult to analyze loads of data in raw log files. So it's not really for human consumption. And without user interface or visualization for this data, how do you analyze logs properly, especially across applications by checking each application's log file and trying to look for similar times to check across applications. Also logs will be in different formats coming from different applications, like the timestamps and log levels, etc. Another option could be to log directly into a log database like Elastic, for example, to then have a visualization of this data. However, in this case, each application developer must add a library for Elastic Search and configure it to connect to Elastic and send those logs. And also each developer must configure the proper format. So again, there's some challenges with this option as well. Now, what about the third-party applications in your cluster, like databases and message broker? Also, in Kubernetes, requests go through NGINX controller. So what if you want to see those logs too? Or what about system logs? You can't control how they log. So how do you collect logs from all these different data sources? All of these are challenges of collecting and consuming logs in complex applications with tons of useful data. Because you have loads of data which you can't really consume and analyze because you don't have it all in one place in a unified format to be able to visualize them properly. So lots of valuable data is kind of wasted. So what is a good solution to that challenge? A technology that lets you collect all the data regardless of where they come from and transform in a unified format all in one place so that you can then use that data, again for compliance or debugging, etc. And that's exactly what FluentD does. And FluentD does that reliably, meaning if there is a network outage or data spikes, this shouldn't mess up data collection, right? So FluentD handles such cases as well. So how does FluentD work and how does it do all of this? FluentD gets deployed into the cluster and it starts collecting logs from all the applications. It can be your own applications, third-party applications, all of it. Now these logs that FluentD collected will be of different forms and formats, right? Like JSON format, NGINX format, some custom format maybe, and so on. So FluentD will process them and reformat them into a uniform way. Now on top of that, you can enrich your data with FluentD. So you can add additional information to each log entry, like pod name, namespace, container name, and so on. So for example, you can later group logs of the same pod or logs of the same namespace. Or you can even modify the data in a log. So now you're streaming your logs from all the applications into one unified format through FluentD. What happens to these logs after FluentD processes them? Well, obviously in most cases, the goal is to nicely visualize them, right? So we can do some analysis on it. Well, FluentD can send these logs to any destination you want. This could be Elasticsearch, MongoDB, S3, Kafka, etc. Now what if you want your Python application logs to go to MongoDB Storage for data analysis and all other application logs to go to Elasticsearch? Or what if you want that Node.js logs also go to the MongoDB in addition to Elasticsearch? You can actually very easily configure that routing in FluentD, which is a great thing about FluentD because it gives you such flexibility compared to alternative tools. So you can send any data from any data source to any destination or storage. And this flexibility also comes from the fact that FluentD is not tied to any particular backend. So you have a wide choice of such destination targets without a vendor lock-in when using FluentD. Now you're probably wondering what you as a FluentD user need to configure and how you can actually use FluentD. First, you must install FluentD in Kubernetes as a demon set. Demon set is a component that runs on each Kubernetes node. So if you have five nodes, they will all have a FluentD pod running on them. You can configure FluentD using a FluentD configuration file. Now FluentD configuration may be a bit complex to get started with, but it's very powerful in terms of processing and reformatting your data. And for that you will use FluentD plugins. FluentD has tons of plugins for different use cases. First of all, you can define the data sources. These are all the applications from which FluentD will start collecting the logs. So first you configure which application logs you want FluentD to start collecting. Second, you configure how these data entries will be processed line by line. So you parse each log as an individual key value pair. You have log level, message, date, user ID, IP address, etc. And you do that in FluentD using parsers. After that you can enrich the data using record transformers. Again to have even more information on that data. Or you can even modify the data. A great use case would be if you want to anonymize personal data in the logs for data protection for example. And finally you have the output. Where should the logs go? And for each such output target there is a plugin like Elasticsearch, MongoDB, and so on. And as you see here in the example configuration file, FluentD has a concept of tags which you can use to group together logs or to filter logs. So using these tags you can say I want all logs with tag myApp to be parsed like that. Or I want logs with the tag myService to go to Elasticsearch and so on. And also using these tags you can easily filter out any unneeded logs to save resources for example. And the flexible routing that I mentioned before, that's why it's easy to configure because using these tags you can very easily configure which logs should go where. So that's basically how you can use FluentD for your logs. Now one big advantage of FluentD is its built-in reliability. When FluentD collects and processes the data it saves it on hard drive until it sends that process data to the configured output destination. This means that if FluentD pod restarts in the middle of collecting or processing the data or the whole server restarts the data will still be there. And when FluentD starts again it can pick up from where it left off. And it also means you don't have to configure any additional storage for FluentD like Redis database and so on. What can also happen is when the back end, the output target is not accessible. It can happen that elastic search is down or MongoDB isn't accessible. In that case FluentD will handle that by automatically retrying to send logs until that endpoint becomes available again. And in addition to that you can also cluster your FluentD setup to make it even more performant and highly available. I should mention here that this is one of the use cases of FluentD which is logging in Kubernetes. However, logging is a very important topic in IoT applications too or in non-containerized applications running on bare metal servers for example. And many projects are using FluentD for those use cases as well. So FluentD can be used in many different environments. If you're interested in learning more about FluentD I recommend checking out the online resources and documentation of FluentD.


Hey guys, it's Nate aka The Foot Accountant. Welcome back to the channel. The first market outlook video of FIFA 20 is here. It's Monday. You know what we do on this channel? During FIFA, we look at the market, take a look at what could be happening for the next week in FIFA Ultimate Team and try to maybe get ahead and basically just plan our week in terms of FIFA and what promotions we could see, what kind of stuff that we could see. Oh, what is this? A celebrations pack. Okay, nice objective right there. But we want to look ahead at this next week of FIFA, kind of look at what we could be seeing, market movements we can prepare for and stuff like that. First thing that I noticed this morning, getting onto the game, 4 million live transfers. Oh man, the squad battles market has influenced a lot of things. Squad battle rewards were last night earlier this morning, and it looks like the number of live transfers has been affected greatly by that. So that's kind of an interesting point that we can start talking about. But the main things that we're going to talk about today are the game rolling out, the pre-order access rolling out today to a lot of people worldwide, I believe, at the time that I'm recording this video. And as this goes live to you guys, I think it's available in like Australia, New Zealand. And that's going to that time frame is going to start sweeping across the globe as they kind of roll the game out. And it doesn't always get released right at midnight Tuesday, wherever you're at in that time zone. Like I think here in the US, the countdown shows that it's going to be live here at 7pm Eastern time, which would be midnight UK. So I guess I don't know if they're releasing it with for the US at the same time as UK. We'll talk about that in a little bit as well. And of course, the stuff that is happening through the rest of the week, what in the world? 75 silver items? What? Celebrations pack? I don't know what this is. Oh my gosh. These are all celebrations. All right, get him in the club. Sweet. 75 celebrations. I was not expecting that pack. All right, there you go, boys. Play a friendly match and you get all those celebrations. Sweet. Anyway, we need to start talking about the market and what's going to be happening this week because there's a lot of stuff that's going to be happening this week. Price is going up. Price is going down. Things that we need to prepare for. So the first thing I want to talk about is the squad battle rewards that were out last night and how that is currently affecting the market. So last night, I'll show you guys my transfer list in a second. I bought into a lot of cards that were SBC fodder and that were low-rated, high-priced, OP prem cards like this SAR. Pulisic was another card that I bought. I bought Luke Shaw and I also bought some Lindgard. I don't have a ton of coins so it didn't, it wasn't, I couldn't do a lot of trading with this. But I also bought a lot of Doherty's because I was low on coins and got a ton of them on bid. So that was big. But basically what I saw last night was squad battle rewards hit the market, hit some prices down right away and then you were available, you were able to do a quick flip with some of these cards that they haven't sold for me just yet. But you were able to do a quick flip with some of these, some of these meta prem cards. People got squad battle rewards, bought them, used them in their team, they got some coins. So that was the whole point of that. And also what I saw interesting last night, I made a tweet about this and I said, you're going to be able to watch the supply of some cards and it might actually show us what kind of market movements we might see on Tuesday when the full game comes out and more packs are open and more people come on the game. What could be happening with that? Like what cards went up last night after getting some supply? Basically what cards are people upgrading to in their teams? And it looks like a lot of these, like I was looking at Shaw and I was looking at SAR and Lindgard, as I mentioned before. And a lot of them went up right away, but now they're kind of just chilling, maybe even down a little bit more from the squad battle time period. And that intrigues me a little bit, means they got a decent amount of supply. But Lindgard is being one of the most used players in FIFA 20. If we use this very popular tool called PGP, over here on Footbin, I'll show you guys in a second. But console PlayStation 4, I always like it sorted by console over here in the PGP tab, so that you know what's going on. But I believe that Lindgard, yeah, Lindgard is right up here with one of the highest amount of games played and his price is still kind of fluctuating a little bit. This is a very important page for you guys to use. Players PGP is where you get your players PGP, click on Games, you can see the most games which cards have been used the most. And this is important for investing and seeing which cards people are using. Maybe you can kind of show you which cards people are upgrading to as well. There's a lot of games being played, obviously Premier League guys are up here at number one. But I think this guy was surprised at me. Morales, the striker, 13K, 82 rated. That's an interesting thing to watch. So watch that this week with Informs, with gold cards to see which cards people are using. But I also, mentioning that, those could be some investments come Tuesday. Because Tuesday, full game release, a whole new wave of people come onto the game, start the game, they don't. They didn't have EA access, maybe they got on the web app for a bit. So they have a little bit of their clubs set up already, maybe not much. But a lot of new people are going to be coming out of the game. And it's going to be sort of like EA access for some cards. Obviously during EA access, we saw big time rises in the market. And some of these cards that people wanted to use for their teams. Even some low rated guys like this Joe Gomez, who is down in price a lot. 5,400 coins. GG. Squad battle rewards is hitting the market, man. So some of those cards are down a lot, but people are going to be buying them up and using them in their teams. So you probably might see an uptick in some of those cards. Especially concerning Joe Gomez is the number one used card on PlayStation 4 in terms of games played. 8,000, Lucas, William, and Dombele, Felipe Anderson, Havards, Rashford, Sasoko, and Pereira are down there as well. But those are the kind of cards you're going to want to watch out for on Tuesday. And we're going to talk about a few different cards to watch out for. You want to focus on those meta and OP cards. They're going to get packed some and they're going to rise right after. So basically what you can expect from Tuesday through the rest of the week is a rise up until Thursday or early morning Friday when the full game releases. Especially for ones to watch investments like this Brant card. He's still chilling around 100, not 100. He's still chilling around 20,000 coins. And Dombele is still right around 22,000 coins. So that's kind of their normal price range as possible ones to watch cards. So those are the kind of cards that you're going to want to watch in the next day or so because this is what I told you guys before. Be looking to invest in some of these ones to watch gold cards that will go out of packs. Tuesday is a great time for that. And especially with these prices already dipping down a little bit. People getting onto the game and opening packs for the first time via the pre-order access. If you ordered like the Ultimate Edition or the Champions Edition. That could be a good shout in the next couple of hours actually. The next day or so. Be watchful on the market for some influx of supply on these players. Wow, that one's actually got a shadow on it. What is the cheapest? What is the cheapest one with a shadow? Yeah, he's probably gone. But let's just see what profit I maybe could have made on that card. So it looks like I could have bought that one for 22 and sold it for 26. Because the cheapest end-down delay with the shadow is 26. So that's a bit of a rip right there. That's another position change or chemistry style trading that you can do with some of those cards. Which just wasn't sure if that was going to work out. Looked like it did. But I'm rambling boys. The big key is Tuesday. More people coming onto the game. The next wave of people are going to be coming onto the game. Which presents a great opportunity to buy some cards because they're going to rise after like the EA access hype where packs are being opened right away and people are getting coins. More packs are going to be opened on Tuesday because people actually have access to the full game. There's no 10 hour trial. Some people that have a ton of FIFA points probably weren't even able to get through them all in 10 hours. So that's a point that has to be made. There's going to be more packs open on Tuesday. Which is going to drop the prices of cards in the short term. And they're really quick like let's say people start rolling onto the game at midnight UK. You're probably going to see the cheapest prices. Morning, mid-morning UK time on Tuesday. So morning, mid-morning UK time on Tuesday. Which will be early morning for me in the US. That's probably when you're going to see some of the cheapest prices from those people that were opening packs. Selling their cards to get coins. And then they're going to go out and buy cards to put in their teams. You're going to see some of those players like people are wondering. You know Lucas Hernandez was extinct at 40k and he's about to go extinct at 50. But I think they upped his price range. Is that true? Is Lucas Hernandez? Yes, they upped his price range to over 50,000 coins. Is he 50k right now? My dude is close to 50k. So like this, Lucas Hernandez card has been going up and up in price. I mean he might get hit with a little bit of supply. But then this is the type of card who I still feel like is a bit undervalued. These types of cards, the markets are really going to sort out their values. And really if there is a card that is still too low, you're going to see it go flying. Because there's going to be a lot more demand for cards in this game come Tuesday. So that's the first point that I wanted to make to you guys today. Tuesday is going to be a great day to invest in the wants to watch golds. And it's going to be a day where we have a lot more people coming on to the game. You're going to see a lot more activity on the market. This number of transfers out here right now at like 4 million, which is pretty high. For this level of game, you're probably going to see this not double, but I think on Tuesday you can see this at maybe 6 million. That's just going to show you how many more people are going to come on to the game. And then of course on Friday, it's going to be crazy high as we have more and more people getting on to the full game than as well. So from Tuesday to Friday, you're going to see prices rise up in just about every single area, except some of these low rated guys. So one example that I think is going to be a perfect example of somebody who's going to lose their value in the next couple of days is going to be Christian Pulaski. He's 25, 2400 coins right now. He got hit a little bit with squad battle rewards supply last night. But this is a 79 rated gold card that this is like a starter team card, like specifically that's it. You're going to use this card and starter team. That's really all you're going to use this card for. And this is the type of cards as we look back in years past. These types of cards get hit big time on Tuesday and they continue to drop into Friday where they get hit even more and basically go to a thousand coins or below. So I think you can expect this Pulaski card to maybe be 2,000 coins for a Tuesday morning. Might drop to 1500 throughout the day Tuesday. So if you're looking to invest in some of these cards, I don't think the gold low ratings are the shout anymore. The guys to invest in are going to be those ones to watch cards that you still think are low. And I'm going to make a video on that here really, really soon. Probably today as well. Double upload on which ones to watch cards you can look out for. Just a couple of names that are off the top of my head. Kailor Navas I think is an interesting one to me. Obviously we looked at Andambole. I think he's going to get a wants to watch. And I think that Brant has a good shout at getting into. So we'll look at some of those cards because Tuesday is going to be a prime opportunity to get those cards if their prices do drop with some supply coming on the game as people open packs. So I want to look at some of that stuff as well. But then heading into Friday, a lot of stuff. If you're investing in a wants to watch card, let's say you're investing in a guaranteed wants to watch like Yovitch. And we'll talk about this in that next video too. A guy like Yovitch, what is he at? Like 6k? 5k? Yeah, somewhere around like 6,000 coins. If it's a guaranteed wants to watch that we already know is coming out of the game, most times you're going to want to sell in the hype on Thursday, okay? Not waiting until Friday when everybody else has the card they've invested in. They know it's going out of packs and they go and sell on Friday and then the price just drops. Like last year we saw that with Gretzger. Gretzger was his highest basically on Thursday before the full game released because he was so over-invested in. Same with Márez. They were pretty invested in. The guys are going to make you coins with the guys that fly under the radar that not as many people are talking about. Maybe a Kailor Navas. If you have a lot of coins, an Antoine Griezmann, I think this card is pretty cheap. Is he still 300k? Yeah, he's right around 300,000 coins, a little bit under 280. I mean, if you can snag this card maybe on a Snipe on Xbox at like two, or excuse me, on PlayStation for like 260 or 270. On Tuesday when a lot of stuff is, oh, 267, okay, maybe 250. If you can get yourself a Griezmann at 250 in some supply, maybe a Snipe or something on Tuesday, that could be a great investment for you. I think he's getting a Once to Watch. So that Once to Watch stuff is going to be big heading into Friday as those cards do go out of packs. And of course, Team of the Week cards as well. We still have a DeYoung card, I think it's extinct still, which is pretty crazy, that this DeYoung card could still be extinct. But there's going to be some supply that comes out for these cards on Tuesday as well. So the big day this week is Tuesday, and then the big, big day is Friday. But we'll talk more about Friday as that comes. I wanted to really just mention the Tuesday stuff, since that is so soon on the market. And yeah, the market this week, you're going to see a lot of things just continue to trend up, meta players, even though you think they're so high and they're not going to go any higher. Let me tell you, they're going to continue to go higher, especially if they are prem, if they are popular cards like this Roger, I think, what is he, like 30K? Is he 30? Ah, he's dropped a bit, dude. Oh, situation with Roger. This is a Once to Watch potential as well. He was like 32 or 33K last night. What's my man now? 28,000 coins. Wow, so he's dropped about 5K. That's a big time. He has a very good card, and there's a huge price discrepancy between him and Fabinho, who are sort of comparable in this game. So that's going to be something to watch as well. If you're on a higher budget, you could drop down 200K on maybe, you know, maybe 10 of these cards, 300,000 coins. That could be a great Once to Watch investment for you. So that's the kind of stuff that we're going to be looking at today and over the next couple of hours as we head into the biggest week on FIFA. The biggest week on FIFA because the game is coming out, I'll say like that. There might be other big weeks on FIFA, but this one's pretty big. So if you enjoyed the video, smash the thumbs up on it. Comment down below if you have any questions and subscribe to the channel if you are new. It's been Nate, The Foot Accountant. Catch you guys later. Peace out.


So many of our prospects ask if there is a month view for when I work. The simple answer is yes. You can easily see a month view by clicking on calendar sync and highlighting the link you want to use. For this one we will choose the entire schedule. Then just log in to the calendar of your choice. Maybe you use Outlook or you use the calendar on your MacBook Pro. For this demonstration we will import this into Google Calendar. So open up your Google Calendar. Click here to add by URL. Paste the text we copied and now you can easily see the whole month. If you want to separate this for just your schedule or a specific location you can do that as well. Just make sure you select the URL that you want in the When I Work app.


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