Patients receive bills for claims their insurers already paid.

This article was published on Thursday, April 7, 2022 in Kaiser Health News.

By Aneri Pattani April 7, 2022

Every now and then, Suzanne Rybak and her husband, Jim, receive pieces of mail addressed to their deceased son, Jameson. Typically, it's junk mail that requires little thought, Suzanne said.

But on March 5, an envelope for Jameson came from McLeod Health.

Jim saw it first. He turned to his wife and asked, "Have you taken your blood pressure medication today?"

He knew showing her the envelope would resurface the pain and anger their family had experienced since taking Jameson to McLeod Regional Medical Center two years ago.

As KHN previously reported, Jameson was experiencing withdrawal symptoms from quitting opioids. Suzanne feared for her son's life and took him to the emergency room near their home in Florence, South Carolina, on March 11, 2020.

There, they encountered a paucity of addiction treatment and the potential for high medical costs — two problems that plague many families affected by the opioid crisis and often lead to missed opportunities to save lives.

Jameson was not offered medications to treat opioid use disorder in the ER, nor was he given referrals to other treatment facilities, Suzanne said. The hospital wanted to admit him, but, being uninsured, Jameson feared a high bill. The hospital didn't inform him of its financial assistance policy, Suzanne said. And he decided to leave.

Three months later, Jameson, 30, died of an overdose in his childhood bedroom.

In the following months, the Rybaks received bills from the McLeod Health system addressed to Jameson. He owed $4,928, it said. Suzanne called and wrote to hospital administrators until September 2020, when the bill was resolved under the system's financial assistance program.

That was the last they had heard from McLeod Health until the new envelope arrived March 5 — one week before the two-year anniversary of his ER visit. That visit was what Suzanne calls "the beginning of the end for my son."

When the Rybaks opened the envelope, they found a strikingly familiar bill for $4,928.

"I can't even describe my anger and sadness," Suzanne said. "It's always present, but when we received that statement, we were just stunned."

There's no national data to indicate how often patients or their families receive medical bills that were previously paid or forgiven, but hospital billing experts say they frequently see it happen. Patients receive bills for claims their insurers already paid. A reminder statement arrives even after a patient submitted payment.

Unlike "surprise bills," which often result from policy gaps when a provider is out of network, these are bills that were resolved but continue to pop up anyway. They can carry financial consequences — patients wind up paying for something they don't truly owe or bills get passed on to debt collection agencies, triggering more phones calls and red tape. But often it's the emotional toll that wears on patients most, spending hours on the phone with customer service each time the bill resurfaces or reliving the situations that led to the bill in the first place. For families like the Rybaks, the cost can feel never-ending.

Suzanne Rybak refused to engage with the McLeod hospital again but told KHN about the new bill.

In response to questions from KHN, McLeod Health determined the bill the Rybaks received was a mistake.

"Unfortunately our software system regenerated this statement due to a technical issue," wrote spokesperson Jumana Swindler. "We are checking to ensure that it has not happened to any other patients and we are sorry this family was impacted by the error."

A week after KHN's inquiry, the Rybaks received a letter from the hospital explaining and apologizing for the error.

Many medical billing cases like this "boil down to human error," said Michael Corbett, director of healthcare consulting for LBMC, a Tennessee-based firm that consults with health systems nationally on issues like billing and revenue. "Facilities don't have a lack of tools [to avoid this]. It's a breakdown in their processes."

A billing agent may forget to mark the account as paid, he said. Or the hospital might contract its billing to an outside company and fail to inform them that this bill was covered under the hospital's financial assistance program.

As hospitals and medical practices increasingly consolidate under large health systems, the chances for errors increase. Even hospitals and clinics within the same system may have different backend software, and within each hospital there can be separate programs for billing and electronic health records, Corbett explained.

Larger health systems may also have more people processing any given bill. If responsibilities are not clearly defined, multiple employees could unknowingly act on the same patient account.

The COVID-19 pandemic has exacerbated potential errors, Corbett said. New medical billing employees may have received quick, virtual training and are working remotely with little interaction with team members or oversight. Some billing departments are understaffed, leading to delays in patients receiving bills or follow-up notices, he added.

To curb mistakes, Corbett said, hospitals need to invest in more comprehensive training and supervision for billing employees; enact consistent processes for anything from how patients' financial information is collected at registration to when they're sent bills; and, perhaps most important, track whether those processes are being followed.

For patients who find themselves in a situation like the Rybak family's, Corbett advises calling the hospital billing department and asking to speak with a senior leader in its revenue cycle division. Unlike an account representative, this person could make decisions, Corbett said.

At the end of the conversation, ask to get the explanation in writing, he added.

"You'd anticipate and hope those notes are being recorded," Corbett said, but that may not be the case. Or notes might get recorded in a section of hospital files that are excluded from a patient's legal medical record, making it difficult for patients to access later.

For Suzanne Rybak, the idea of calling McLeod Health to straighten out yet another bill was too much. Instead, she added the statement to a binder of paperwork, in which she's documented all her billing struggles with McLeod Health over the past two years.

Still, out of sight hardly means out of mind. The binder sits in her craft room, where she remembers Jameson encouraging her as she made beach bags and other items. He'd say to use "fruity colors," Suzanne recalled — his way of describing tropical colors. Now she makes candles in that room, focusing on tropical fragrances she knows Jameson would have loved.

"I want hospitals to realize that you're not just sending this bill to an address," Suzanne said. "There are people who live in that house, who are going to open that mail and have feelings. … It's a disaster to bring all that up again."

Aneri Pattani: apattani@kff.org, @aneripattani

Nurses warn that the fallout will ripple through their profession, demoralizing and depleting the ranks of nurses already stretched thin by the pandemic. Ultimately, they say, it will worsen healthcare for all.

This article was published on Tuesday, April 5, 2022 in Kaiser Health News.

By Brett Kelman and Hannah Norman

Emma Moore felt cornered. At a community health clinic in Portland, Oregon, the 29-year-old nurse practitioner said she felt overwhelmed and undertrained. Coronavirus patients flooded the clinic for two years, and Moore struggled to keep up.

Then the stakes became clear. On March 25, about 2,400 miles away in a Tennessee courtroom, former nurse RaDonda Vaught was convicted of two felonies and facing eight years in prison for a fatal medication mistake.

Like many nurses, Moore wondered if that could be her. She'd made medication errors before, although none so grievous. But what about the next one? In the pressure cooker of pandemic-era healthcare, another mistake felt inevitable.

Four days after Vaught's verdict, Moore quit. She said Vaught's verdict contributed to her decision.

"It's not worth the possibility or the likelihood that this will happen," Moore said, "if I'm in a situation where I'm set up to fail."

In the wake of Vaught's trial ― an extremely rare case of a healthcare worker being criminally prosecuted for a medical error ― nurses and nursing organizations have condemned the verdict through tens of thousands of social media posts, shares, comments, and videos. They warn that the fallout will ripple through their profession, demoralizing and depleting the ranks of nurses already stretched thin by the pandemic. Ultimately, they say, it will worsen healthcare for all.

Statements from the American Nurses Association, the American Association of Critical-Care Nurses, and the National Medical Association each said Vaught's conviction set a "dangerous precedent." Linda Aiken, a nursing and sociology professor at the University of Pennsylvania, said that although Vaught's case is an "outlier," it will make nurses less forthcoming about mistakes.

"One thing that everybody agrees on is it's going to have a dampening effect on the reporting of errors or near misses, which then has a detrimental effect on safety," Aiken said. "The only way you can really learn about errors in these complicated systems is to have people say, 'Oh, I almost gave the wrong drug because …'

"Well, nobody is going to say that now."

Fear and outrage about Vaught's case have swirled among nurses on Facebook, Twitter, and Reddit. On TikTok, a video platform increasingly popular among medical professionals, videos with the "#RaDondaVaught" hashtag totaled more than 47 million views.

Vaught's supporters catapulted a plea for her clemency to the top of Change.org, a petition website. And thousands also joined a Facebook group planning to gather in protest outside Vaught's sentencing hearing in May.

Ashley Bartholomew, 36, a Tampa, Florida, nurse who followed the trial through YouTube and Twitter, echoed the fear of many others. Nurses have long felt forced into "impossible situations" by mounting responsibilities and staffing shortages, she said, particularly in hospitals that operate with lean staffing models.

"The big response we are seeing is because all of us are acutely aware of how bad the pandemic has exacerbated the existing problems," Bartholomew said. And "setting a precedent for criminally charging [for] an error is only going to make this exponentially worse."

Vaught, who worked at Vanderbilt University Medical Center in Nashville, was convicted in the death of Charlene Murphey, a 75-year-old patient who died from a drug mix-up in 2017. Murphey was prescribed a dose of a sedative, Versed, but Vaught accidentally withdrew a powerful paralyzer, vecuronium, from an automated medication-dispensing cabinet and administered it to the patient.

Prosecutors argued that Vaught overlooked many obvious signs she'd withdrawn the wrong drug and did not monitor Murphey after she was given a deadly dose. Vaught owned up to the error but said it was an honest mistake ― not a crime.

Some of Vaught's peers support the conviction.

Scott Shelp, a California nurse with a small YouTube channel, posted a 26-minute self-described "unpopular opinion" that Vaught deserves to serve prison time. "We need to stick up for each other," he said, "but we cannot defend the indefensible."

Shelp said he would never make the same error as Vaught and "neither would any competent nurse." Regarding concerns that the conviction would discourage nurses from disclosing errors, Shelp said "dishonest" nurses "should be weeded out" of the profession anyway.

"In any other circumstance, I can't believe anyone ― including nurses ― would accept 'I didn't mean to' as a serious defense," Shelp said. "Punishment for a harmful act someone actually did is justice."

Vaught was acquitted of reckless homicide but convicted of a lesser charge, criminally negligent homicide, and gross neglect of an impaired adult. As outrage spread across social media, the Nashville district attorney's office defended the conviction, saying in a statement it was "not an indictment against the nursing profession or the medical community."

"This case is, and always has been, about the one single individual who made 17 egregious actions, and inactions, that killed an elderly woman," said the office's spokesperson, Steve Hayslip. "The jury found that Vaught's actions were so far below the protocols and standard level of care, that the jury (which included a longtime nurse and another healthcare professional) returned a guilty verdict in less than four hours."

The office of Tennessee Gov. Bill Lee confirmed he is not considering clemency for Vaught despite the Change.org petition, which had amassed about 187,000 signatures as of April 4.

Lee spokesperson Casey Black said that outside of death penalty cases the governor relies on the Board of Parole to recommend defendants for clemency, which happens only after sentencing and a board investigation.

But the controversy around Vaught's case is far from over. As of April 4, more than 8,200 people had joined a Facebook group planning a march in protest outside the courthouse during her sentencing May 13.

Among the event's planners is Tina Visant, the host of "Good Nurse Bad Nurse," a podcast that followed Vaught's case and opposed her prosecution.

"I don't know how Nashville is going to handle it," Visant said of the protest during a recent episode about Vaught's trial. "There are a lot of people coming from all over."

Hannah Norman: hannahn@kff.org, @hnorms

Pennsylvania's Mifflin County offers a snapshot into how one hard-hit community, with more than 300 dead, is coping.

This article was published on Friday, April 1, 2022 in Kaiser Health News.

McVEYTOWN, PA — Connie Houtz didn't think COVID would be that bad.

She'd seen many people in this rural hamlet in central Pennsylvania get infected yet recover within a few days. She did not get vaccinated because she worried about how a new vaccine, developed in record time, might affect her heart condition.

Last October, her youngest son, 45-year-old Eric Delamarter, developed a chest cold. He put off going to the doctor because he had customers waiting at his shop where he repaired cars, she said. When he finally went to the emergency room at Geisinger Lewistown Hospital, he was diagnosed with pneumonia and COVID.

Within a few days, Houtz's oldest son, 50-year-old Toby Delamarter, had also been admitted to the hospital with the virus and shortness of breath.

Less than two weeks later, both of her sons were dead. Neither had been vaccinated.

"Even though it does not seem fair and does not seem right, down the road we will find a reason for why things happen," said Houtz, 71, as she sat at her kitchen table.

Eric and Toby Delamarter are two of the roughly 300 people who have died of COVID in Mifflin County, where cows grazing in pastures and Amish horse and buggies are frequent sights. The county 60 miles northwest of Harrisburg leans heavily Republican — 77% of votes cast in 2020 were for Donald Trump — and the former president's downplaying of COVID-19 found fertile ground there.

Mifflin has one of the highest COVID death rates among U.S. counties with at least 40,000 people, according to government data compiled by Johns Hopkins University — 591 deaths per 100,000 residents as of mid-March, compared with 298 deaths nationally.

The United States is nearing 1 million deaths from COVID — a number that few thought possible when the pandemic began.

In March 2020, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said that based on modeling of the pace of the coronavirus's spread in the U.S. at that time, "between 100,000 and 200,000" people may die from COVID.

Reaching a million deaths seemed even more improbable when safe and effective vaccines came onto the market in December 2020. More than 60% of the 977,000 deaths have occurred since then.

Mifflin County offers a snapshot into how one hard-hit community moved from skepticism about the scientific reality of the COVID virus, and then about the vaccine, to coping with unbearable loss and processing the trauma. Roughly 8 in 10 deaths nationwide from April to December 2021 were among the unvaccinated, according to the latest analysis of data from 23 states and New York City and Seattle by the Centers for Disease Control and Prevention.

Mifflin County Coroner Daniel Lynch isn't over the stress of COVID even as deaths have declined this year. As of mid-March, his office had counted 337 COVID deaths in the county — about 60 more than the official tally kept by the state. That's because the coroner counts anyone who dies in the county, including those who lived in other counties. Among the people in the coroner's count, 311 hadn't received even one COVID shot. Few residents wore masks even when cases were high nationally and locally.

"It was pure hell," Lynch said. "I have been a coroner since 1996 and never got calls from nurses reporting deaths crying on the phone or facilities reporting two or three deaths at one time."

In Lewistown, the county seat, finding people who knew some of the dead is easy.

At the Corner Lunchbox on a recent afternoon, hands of all five employees and customers quickly shot up when asked whether they knew anyone killed by COVID. Sheila Saurbeck, 65, a manager, said she had lost two friends. And she had COVID herself last year, recovering after a couple of weeks.

Behind the counter was owner Lorrie Sirgey, 56. She said she was hospitalized with COVID for four days last spring before she got vaccinated. "It's been a scary time," she said.

As elsewhere in the country, Mifflin County has seen COVID cases fall dramatically since January. It's unusual to see anyone wearing masks. Health experts point to several factors behind Mifflin County's high death rate:

• A large older population — 22% of residents are 65 or older.
   
• A low COVID vaccination rate (51% of residents are fully vaccinated, compared with 63% statewide).
   
• The prominent Amish and Mennonite populations; Amish people make up over 8% of county residents. Members of those communities largely did not get vaccinated and often gathered for large weddings and funerals during the past two years, according to county officials. Amish, in particular, have low rates of vaccination because they are leery of government intervention and rely on family traditions for preventive medicine.

Mifflin County Commissioner Kevin Kodish also blames politics.

"We are very rural here," he said. "It's heavy Republican and heavy in Trump support, so in the beginning people were skeptical of COVID because he downplayed the disease. And I think that carried over with skepticism with vaccines."

Having so many deaths in the county of about 45,000 people is difficult to comprehend, he added. His 94-year-old mother, who was living in a nursing home, died last year not long after her own bout with COVID.

Kodish, the only Democrat on the three-member County Commission, said COVID split the community, between people who took the disease seriously and got vaccinated, practiced physical distancing, and wore masks and others who just wanted to live their regular lives.

Although COVID has been devastating to many families, the Republican mayor of Lewistown, Deborah Bargo, acknowledged the death toll but focused on how her town's economy is improving.

"It's been hard for those who have lost loved ones, and that pain never goes away," said Bargo, who has been mayor for 15 years. "But, economically, we've bounced back."

Bargo pointed out that nearly every storefront in the downtown square is occupied, a century-old theater is being restored, and a young Mennonite entrepreneur has recently opened a cafe-bakery.

She said she is worried that many older people who stayed in their homes because of fears about COVID have been forever changed by the isolation. In her church, she said, people who wear masks still sit away from everyone else.

Noah Wise, 59, a road supervisor in Burnham, just north of Lewistown, said he's not coping well. His wife, Lisa, a nurse at Geisinger's outpatient care department, died of COVID in December. She was 58 and not vaccinated because she was worried how the vaccine would affect a chronic health condition — even though health experts say people with chronic health issues are more likely to suffer severe consequences and death from COVID.

Wise said Lisa likely caught the virus from him after he was infected in October. "She had no regrets about not being vaccinated," Wise said. "She thought she would pull through."

His wife's death has not persuaded him to get vaccinated because he believes his earlier infection has given him immunity. Natural immunity does confer some resistance to catching the disease but is highly variable in strength, so health experts urge those who have been infected to get vaccinated.

Jenny Barron Landis, executive director of the Juniata River Valley Visitors Bureau, which covers Mifflin County, said many community members were not interested in taking orders from government scientists. "We have a lot of independent farmers and business owners that didn't agree with or honor the mandates, and that has played a big role here in the number of deaths and the number of cases," she said.

Against that backdrop, Geoff Burke, a local funeral director, recalled weeks when his Lewistown funeral home would handle up to 17 deaths, many of them from COVID — triple its average. "We were overwhelmed," he said. "COVID just ravaged our town as it went from nursing home to nursing home."

On March 15, Geisinger Lewistown, a 133-bed hospital, had just two COVID patients, down from 50 earlier this winter, said Dr. Michael Hegstrom, chief medical officer for the region of Geisinger that includes Mifflin County. Geisinger refused to disclose what percentage of its employees at the Lewistown hospital have been vaccinated for COVID. It would say only that all its employees are either vaccinated or received an exemption. Geisinger also refused to disclose how many of its employees in Lewistown died of COVID.

Yet the hospital is still being affected by the virus. It is running above capacity because of high numbers of patients with medical issues such as heart disease and cancer who put off care during the pandemic, Hegstrom said.

Connie Houtz said that the deaths of Eric and Toby — two of her three children — had been hard but that she was thankful for family and friends and strong faith. She remembers Toby — who had some health problems, including cancer of the small intestine a few years ago — as "easygoing and a big teddy bear." Eric, who had high blood pressure, loved spending time with his daughter and taking the teenager fishing, Houtz said.

Both brothers rode Harley-Davidson motorcycles and would hang out with friends at a bar near her house. "It still hits you at times that they are really gone," she said.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Even before covid engulfed the country, many states were giving pharmacists a bigger role in consumers' health.

This article was published on Thursday, March 31, 2022 in Kaiser Health News.

By Michelle Andrews

When Reyna or Justin Ansley or one of their three kids feels sick and needs to be tested for strep throat or flu, there’s a good chance they’ll head to their local pharmacy in Hemingford or Alliance, Nebraska. Dave Randolph, the proprietor of both locations of Dave’s Pharmacy, can do a rapid test, give them medicine if they need it, and send them on their way.

“I’m a cattle rancher,” said Reyna Ansley, whose family lives about 15 miles outside Hemingford. “You don’t necessarily have the time to drive to the doctor and sit in the waiting room. It’s really quicker through Dave.”

The Ansleys don’t have health insurance and using the pharmacy, where Randolph charges $50 to $60 to do the tests, is cheaper than paying up to $200 for an office visit with a local doctor, Ansley said. If the test is positive, the medications generally cost $20 to $30.

Randolph’s ability to provide treatments for flu and strep throat is somewhat unusual. He can do so in Nebraska because he has an annual collaborative practice agreement with a local doctor that is subject to state approval.

The easy availability of pharmacists also helped propel them into a key role during the pandemic as they became a go-to resource for covid-19 testing and vaccines. Yet even before covid engulfed the country, many states were giving pharmacists a bigger role in consumers’ health.

According to the National Alliance of State Pharmacy Associations, more than a dozen states have expanded what pharmacists can do to include testing and treating people for illnesses such as strep throat, flu, and urinary tract infections and preventing HIV. Some states allow pharmacists to prescribe oral contraceptives or drugs to help people quit smoking. Typically, pharmacists have prescribing authority under agreements with doctors or rules called statewide protocols.

But a limited number of states have gone further, allowing pharmacists to prescribe medications on their own to treat a broad range of conditions for which there are rapid point-of-care tests, if it’s appropriate based on clinical guidelines.

“We’re seeing more states looking at direct prescribing authority now as opposed to collaborative practice agreements,” said Allie Jo Shipman, director of state policy at the National Alliance of State Pharmacy Associations. The alliance offers point-of-care testing and point-of-care treating training programs for pharmacists and pharmacy students.

The Biden administration, which has leaned on pharmacies to help battle the covid pandemic by administering vaccines and tests, is now calling for a limited number of pharmacies with retail clinics that employ doctors or other health care workers with prescribing authority to directly provide medication rapidly to people who test positive for the virus. The “test-to-treat” program is designed to make sure that people with covid get a course of antiviral medication quickly because it is most effective if used within five days of when someone shows symptoms.

Pharmacists say their expanded efforts on covid have helped raise their profile.

“One of the big things that came out of covid is that consumers understand that pharmacies do offer these services that are high-quality and convenient and support their health,” said B. Douglas Hoey, CEO of the National Community Pharmacists Association, which represents the interests of independent pharmacists.

But physicians don’t necessarily welcome this development. Doctor groups have long objected to the taking on of certain types of patient care by pharmacists, nurse practitioners, physician assistants, and other nondoctors unless it is overseen by or approved by physicians.

In November, the American Medical Association, which represents doctors, announced that since 2019, it had successfully opposed more than 100 legislative actions that would have expanded nonphysicians’ scope of practice, called scope creep. The group also issued a statement criticizing the Biden administration’s plan to allow pharmacy-based clinics to prescribe covid antiviral medications, saying that the program poses a danger to patient safety and risks negative health outcomes. And the AMA unsuccessfully opposed a federal decision to let pharmacists give covid vaccines to children younger than 18.

Meanwhile, the American College of Physicians, which represents internists, announced it “opposes independent pharmacist prescriptive privileges and initiation of drug therapy outside of a collective practice agreement, physician standing order or supervision, or similar arrangement.”

The AMA didn’t respond to questions about independent pharmacist prescribing, and the ACP declined to comment on its policy.

But are physicians correct that patient safety is at risk if a doctor isn’t involved in prescribing decisions? Pharmacists say that they want to provide care in line with their training and skills and that they know their limits. And they note that timely prescribing is vital for treating covid and other infectious diseases.

They also note that pharmacists are increasingly part of the multidisciplinary clinical teams that direct patient care at hospitals and in health care systems.

“Pharmacists are the professionals that are the most trained to deal with drug interactions,” said Rita Jew, a pharmacist who is president of the Institute for Safe Medication Practices, a nonprofit that focuses on preventing medication errors. “We monitor patients for both efficacy and side effects. So from that perspective, it’s not a safety concern. Delay in treatment is a concern.”

Many pharmacists are eager to expand their menu of patient services, but payment remains a problem. Pharmacists aren’t generally recognized as service providers under Medicare and don’t typically receive payment when they spend time evaluating, testing, or treating patients. Many private insurers follow Medicare’s lead on payment.

For many people, pharmacies are convenient and familiar. More than 90% of people in the United States live within 5 miles of a community pharmacy, and Medicare beneficiaries visit the pharmacy nearly twice as often as they do their primary care physician.

Dr. Jeffrey Singer, a general surgeon and a senior fellow at the libertarian Cato Institute, wrote a recent blog post suggesting that doctors who object to nonphysician prescribing may be more worried about competition than patient safety.

“Rather than work to prevent laws that could meet the needs of patients, the onus is on the profession to persuade people that they need to see a doctor,” Singer said in an interview, adding that he has relied on pharmacists’ expertise in his practice. “I ask them, ‘Is there any particular problem with this drug?’ They have the software. And that’s what they’re trained to do.”

In Arkansas, a 2021 law gave pharmacists the authority to treat conditions for which there are point-of-care tests, as long as they follow statewide protocols established by the state board of pharmacy and the state medical board.

“There are myriad tests that are on the market now that are quick and inexpensive and that can really increase access dramatically for folks who don’t have time or resources to go to a primary care provider,” said Scott Pace, a pharmacist and co-owner of Kavanaugh Pharmacy in Little Rock, Arkansas.

But pharmacists aren’t interested in replacing physicians, said Shipman. “We want to come alongside physicians,” she said. “We want to be another health care provider. In the middle of the pandemic, we need more help. The burden is too great to be carried by any one provider.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.