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First, Universal Coverage. Then, a New Framework.

Question: What are the steps we need to take to arrive at this perfect system?

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George Halvorson: I think that we need two steps in the current process. I don't think we should think of it as just one big leap from here to where we are going. It's a two-step process. And the first step is: we have to get everybody covered. We have to have universal coverage; we have to have all the kids of America in a database where we can deal with asthma issues. We have to have everybody insured. Now that's the first stage. And we have to make them affordable.

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And the second thing, and we have to do this very quickly, is we then have to improve care. Because we cannot afford the care of trajectory were on. We can't afford to have twice as many people with kidneys failing; we can't afford to have 23% of the people dying of sepsis in hospitals. That's the trajectory we can’t afford. We've got to fix that second. One bill can't fix both. One bill can't do all the insurance reform and to the care improvement reforms. So it's got to be a bill and a bill. It's got to be the bill and an agenda. Fill in a leadership and that is the model we have to use. And you can't get there just in one jump.

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The hearings a year ago in the Senate were trying to deal with both of those issues at the same time and there were some very good conversations going on about the chronic care issues in America and the need to fix chronic care. And then there was a sense of who we're trying to figure out what step one and step two – that we have to get to step one as being the insurance part of the agenda, the coverage. Step two is to follow immediately thereafter. They can't follow two years from now or five years from now-- it has to follow months from now. And we need to jump on the agenda and fix a couple of those key issues and get people to pay out to do that. And I think America is ready for that. I think America is ready get healthier, but we have to be led there.

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Question: What’s the logic in putting universal coverage first rather than first fixing the framework?

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Halvorson: Well, number one; we’ve got to get those issues out of the way. If we try to fix diabetic care for the country, and we’ve got 30 million people, many of whom have high diabetic needs, not covered, we can’t do it. If we’ve got all those kids who have horrible asthma care not covered, in a care system, out of a care system, in an insurance plan, out of a care system, we can’t fix asthma care. We can’t do step two until we do step one. We’ve got to get everybody covered. Everybody in this country has to have access to care, and then we need to fix the care. But we need to fix it now. We needn’t fix it 10 years from now. And we know now what needs to be done for asthmatics. We know what needs to be done for people with congestive heart failure. We know what those issues are, we just have to get to them, but we can’t get to them until everybody has insurance. If somebody does not have an insurance plan and they have congestive heart failure, who, or what could possibly make their care better? Nothing. You’ve got to step one, step two. And if you think we’re going to somehow, playing with a horrible handicap, playing left-handed and blindfolded without everybody covered, we’re going to fix care, then after we fix care we’re going to come back and fix insurance. Anybody who thinks that way has never actually been involved in any care delivery or care financing. At Kaiser Permanente, we can’t fix care for the people who don’t have coverage. But we can do a lot for the people who do have coverage.

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Question: How should employers be treated in the model?

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George Halvorson: Most of Europe provides universal coverage and uses private health plans in an employer based system. So, if you’re in the Netherlands, a percentage of your paycheck goes to your healthcare benefit and you choose from 120 health plans. And you pick the health plan and that health plan must take you. It’s an individual mandate. The heath plan must take you. No health screening. If you are in Switzerland, your employer deducts part of your paycheck and you get a health plan, and there are 70 health plans in Switzerland and you get to choose among them. Germany has 300 health plans. Everybody in Germany picks private plans. Those countries have no government system of any kind. They do not have anything resembling Medicare or Medicaid, anything. They just basically have private health plans and an employer-based system. And the employers use their leverage as purchasers to get better deals for their workers and also to get health improvement agendas and health spas and that type of thing. So, if you are in Germany, the employers will negotiate spa treatments on top of the basic health benefits for workers. So involving employers in the model works just fine as long as care is affordable.

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All those countries deduct from the paycheck even if you go to France, where they have a mixed system. The France system looks an awful lot like the Medicare, Medicare supplement model in the U.S. Everybody has a basic benefit package from the government, but it’s low, so 92% of the people buy private insurance and that private insurance pays the difference between what the government pays and what the doctor’s charge. And again, that model is done by employer. And France actually has many healthcare coops and many employers and municipalities will get together and create a coop, libraries will get together and create a coop. There are a whole bunch of coops in France and the French coops purchase care for workers, but again it’s a worker-based system-- everybody pays a portion of their paycheck to buy it. So, most of Europe is a payroll deduction, just like Medicare in the U.S. Social Security in the U.S. They used the same model in those countries, and then you get to choose between health plans.

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So, having employers in the link can be done and it works just fine. The problem in the U.S. the reason it’s failed here is because, in those countries, every employer must be in. In the U.S., it’s optional. Some are in, some are out. Workers don’t know if they’re going to have health coverage. There’s an inconsistency in the American model that doesn’t exist in those other countries. But having employers in can be done just fine.

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Recorded on: September 21, 2009

Healthcare reform is off the ground. What now? Kaiser Permanente CEO George Halvorson outlines the next steps we need to take to arrive at the perfect healthcare system.

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A massive star has mysteriously vanished, confusing astronomers

A gigantic star makes off during an eight-year gap in observations.

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  • The massive star in the Kinsman Dwarf Galaxy seems to have disappeared between 2011 and 2019.
  • It's likely that it erupted, but could it have collapsed into a black hole without a supernova?
  • Maybe it's still there, but much less luminous and/or covered by dust.

A "very massive star" in the Kinman Dwarf galaxy caught the attention of astronomers in the early years of the 2000s: It seemed to be reaching a late-ish chapter in its life story and offered a rare chance to observe the death of a large star in a region low in metallicity. However, by the time scientists had the chance to turn the European Southern Observatory's (ESO) Very Large Telescope (VLT) in Paranal, Chile back around to it in 2019 — it's not a slow-turner, just an in-demand device — it was utterly gone without a trace. But how?

The two leading theories about what happened are that either it's still there, still erupting its way through its death throes, with less luminosity and perhaps obscured by dust, or it just up and collapsed into a black hole without going through a supernova stage. "If true, this would be the first direct detection of such a monster star ending its life in this manner," says Andrew Allan of Trinity College Dublin, Ireland, leader of the observation team whose study is published in Monthly Notices of the Royal Astronomical Society.

So, em...

Between astronomers' last look in 2011 and 2019 is a large enough interval of time for something to happen. Not that 2001 (when it was first observed) or 2019 have much meaning, since we're always watching the past out there and the Kinman Dwarf Galaxy is 75 million light years away. We often think of cosmic events as slow-moving phenomena because so often their follow-on effects are massive and unfold to us over time. But things happen just as fast big as small. The number of things that happened in the first 10 millionth of a trillionth of a trillionth of a trillionth of a second after the Big Bang, for example, is insane.

In any event, the Kinsman Dwarf Galaxy, or PHL 293B, is far way, too far for astronomers to directly observe its stars. Their presence can be inferred from spectroscopic signatures — specifically, PHL 293B between 2001 and 2011 consistently featured strong signatures of hydrogen that indicated the presence of a massive "luminous blue variable" (LBV) star about 2.5 times more brilliant than our Sun. Astronomers suspect that some very large stars may spend their final years as LBVs.

Though LBVs are known to experience radical shifts in spectra and brightness, they reliably leave specific traces that help confirm their ongoing presence. In 2019 the hydrogen signatures, and such traces, were gone. Allan says, "It would be highly unusual for such a massive star to disappear without producing a bright supernova explosion."

The Kinsman Dwarf Galaxy, or PHL 293B, is one of the most metal-poor galaxies known. Explosive, massive, Wolf-Rayet stars are seldom seen in such environments — NASA refers to such stars as those that "live fast, die hard." Red supergiants are also rare to low Z environments. The now-missing star was looked to as a rare opportunity to observe a massive star's late stages in such an environment.

Celestial sleuthing

In August 2019, the team pointed the four eight-meter telescopes of ESO's ESPRESSO array simultaneously toward the LBV's former location: nothing. They also gave the VLT's X-shooter instrument a shot a few months later: also nothing.

Still pursuing the missing star, the scientists acquired access to older data for comparison to what they already felt they knew. "The ESO Science Archive Facility enabled us to find and use data of the same object obtained in 2002 and 2009," says Andrea Mehner, an ESO staff member who worked on the study. "The comparison of the 2002 high-resolution UVES spectra with our observations obtained in 2019 with ESO's newest high-resolution spectrograph ESPRESSO was especially revealing, from both an astronomical and an instrumentation point of view."

Examination of this data suggested that the LBV may have indeed been winding up to a grand final sometime after 2011.

Team member Jose Groh, also of Trinity College, says "We may have detected one of the most massive stars of the local Universe going gently into the night. Our discovery would not have been made without using the powerful ESO 8-meter telescopes, their unique instrumentation, and the prompt access to those capabilities following the recent agreement of Ireland to join ESO."

Combining the 2019 data with contemporaneous Hubble Space Telescope (HST) imagery leaves the authors of the reports with the sense that "the LBV was in an eruptive state at least between 2001 and 2011, which then ended, and may have been followed by a collapse into a massive BH without the production of an SN. This scenario is consistent with the available HST and ground-based photometry."

Or...

A star collapsing into a black hole without a supernova would be a rare event, and that argues against the idea. The paper also notes that we may simply have missed the star's supernova during the eight-year observation gap.

LBVs are known to be highly unstable, so the star dropping to a state of less luminosity or producing a dust cover would be much more in the realm of expected behavior.

Says the paper: "A combination of a slightly reduced luminosity and a thick dusty shell could result in the star being obscured. While the lack of variability between the 2009 and 2019 near-infrared continuum from our X-shooter spectra eliminates the possibility of formation of hot dust (⪆1500 K), mid-infrared observations are necessary to rule out a slowly expanding cooler dust shell."

The authors of the report are pretty confident the star experienced a dramatic eruption after 2011. Beyond that, though:

"Based on our observations and models, we suggest that PHL 293B hosted an LBV with an eruption that ended sometime after 2011. This could have been followed by
(1) a surviving star or
(2) a collapse of the LBV to a BH [black hole] without the production of a bright SN, but possibly with a weak transient."

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