Right, and if we could cut back on some of our non-essentials like pet, bottled water, holiday, sports expenses and stop shopping while drunk, and get our kids to step up and earn their own damn money, we should easily be able to stop borrowing for things that really matter like their healthcare.Originally Posted by tooblue
One point of clarification: Americans borrowed 88 billion. Now, consider the interest paid on that 88 billion ... that's what Americans spent.
“To me there is no dishonor in being wrong and learning. There is dishonor in willful ignorance and there is dishonor in disrespect.” James Hatch, former Navy Seal and current Yale student.
Self-righteous Canuck!
"It is only with the heart that one can see rightly; what is essential is invisible to the eye."
--Antoine de Saint-Exupery
"Things fall apart; the centre cannot hold."
--Yeats
“True, we [lawyers] build no bridges. We raise no towers. We construct no engines. We paint no pictures - unless as amateurs for our own principal amusement. There is little of all that we do which the eye of man can see. But we smooth out difficulties; we relieve stress; we correct mistakes; we take up other men's burdens and by our efforts we make possible the peaceful life of men in a peaceful state.”
--John W. Davis, founder of Davis Polk & Wardwell
Which one of these should not be like the others:
I can borrow money to start a business
I can borrow money to secure a home
I can borrow money to purchase a car
I can borrow money to pay for hip replacement surgery
Last edited by tooblue; 04-03-2019 at 05:55 AM.
You have not really mastered debating. (snicker)
To strengthen you argument about the unreasonable costs of American healthcare, you should replace "can" with "need to".
The difference I see among the 4 examples is that with the first three, there is something with equity that secures the loan. For surgery, it's just your signature. It's pretty hard to get any resale value from an artificial hip. (I'm assuming a bit here, Hostile can set me straight if I'm wrong)
“To me there is no dishonor in being wrong and learning. There is dishonor in willful ignorance and there is dishonor in disrespect.” James Hatch, former Navy Seal and current Yale student.
Actually "can" is the correct word to use, because per the American philosophy on health care, a hip replacement isn't considered a "need", but rather a want and thus, one can pay for a hip replacement.
Further, how distorted is a perspective that even jokingly equates hip replacement with equity?
According to the following metrics, the US ranks 27th in the world for it's levels of health care:
http://www.healthdata.org/research-a...ries-1990-2016
https://www.businessinsider.com/us-r...ucation-2018-9
Right. Ask Roger Reid or Bo Jackson if hip replacement is a want vs. a need. I guess technically people don't "want" to be disabled with debilitating pain.Actually "can" is the correct word to use, because per the American philosophy on health care, a hip replacement isn't considered a "need", but rather a want and thus, one can pay for a hip replacement.
Further, how distorted is a perspective that even jokingly equates hip replacement with equity?
According to the following metrics, the US ranks 27th in the world for it's levels of health care:
http://www.healthdata.org/research-a...ries-1990-2016
https://www.businessinsider.com/us-r...ucation-2018-9
So how do they handle them in Canada? Are they not offered because they aren't considered a need? Or is it the same cost as replacing the u-joints on your car, only with a two-year waiting list?
“To me there is no dishonor in being wrong and learning. There is dishonor in willful ignorance and there is dishonor in disrespect.” James Hatch, former Navy Seal and current Yale student.
I don’t know or care whether Canada’s healthcare system is better or more cost efficient than the US. I don’t live in Canada. All I know is that the US system is broken and neither party is really addressing the issues. It has been breaking for 20+ years and the GOP has no plan. Obamacare was a plan, but only addressed the insurance side of the problem and that, while beneficial to many, was also detrimental to many. It will continue to be an issue that will be batted back and forth with no meaningful change. When the cost of healthcare is greater than the cost of housing, even before seeing a doctor, that is a problem.
Yay socialized medicine!
https://twitter.com/STcom/status/111...690160129?s=19
"Be a philosopher. A man can compromise to gain a point. It has become apparent that a man can, within limits, follow his inclinations within the arms of the Church if he does so discreetly." - The Walking Drum
"And here’s what life comes down to—not how many years you live, but how many of those years are filled with bullshit that doesn’t amount to anything to satisfy the requirements of some dickhead you’ll never get the pleasure of punching in the face." – Adam Carolla
I think that’s a micro-aggression.
"It is only with the heart that one can see rightly; what is essential is invisible to the eye."
--Antoine de Saint-Exupery
"Things fall apart; the centre cannot hold."
--Yeats
“True, we [lawyers] build no bridges. We raise no towers. We construct no engines. We paint no pictures - unless as amateurs for our own principal amusement. There is little of all that we do which the eye of man can see. But we smooth out difficulties; we relieve stress; we correct mistakes; we take up other men's burdens and by our efforts we make possible the peaceful life of men in a peaceful state.”
--John W. Davis, founder of Davis Polk & Wardwell
I don't think anyone is arguing that socialized medicine has all of the answers for US healthcare problems. I am sure if you dig hard enough you can find some sort of statistic on how many in the US go without cataract surgery due to lack of money/health insurance. There must be a few in that category, but that is really beside the point.
Posts like these illustrate the problem with our discourse and our inability to find answers. For years the GOP railed on Obamacare but offered no plan to address the issues. Two years into total GOP control, still no plan other than repeal Obamacare and meaningless crap about a plan in 2020.
I know this constant criticism with no solutions goes both ways. For me, the opinions of critics are worthless unless they also contain realistic and viable solutions.
Since you are calling me out I have actually gave a solution. I have sent this to a my state congressman, and my national congressman and senator. I just saw this yesterday and decided to post.
"Be a philosopher. A man can compromise to gain a point. It has become apparent that a man can, within limits, follow his inclinations within the arms of the Church if he does so discreetly." - The Walking Drum
"And here’s what life comes down to—not how many years you live, but how many of those years are filled with bullshit that doesn’t amount to anything to satisfy the requirements of some dickhead you’ll never get the pleasure of punching in the face." – Adam Carolla
Yay US medicine—I can get the surgery if I can pay for it. If not, maybe the Knights Templar Eye Foundation will spot me the cash!
https://www.keranews.org/post/simple...cant-afford-it
https://www.aao.org/eyenet/article/h...-who-can-t-pay
Europe’s Alternative to Medicare for All
Swiss and Dutch private insurance provide better coverage than Canada’s single-payer system.
By Regina E. Herzlinger and
Bacchus Barua
April 16, 2019 7:33 p.m. ET
Sen. Bernie Sanders described his Medicare for All legislation in a Fox News town hall the other night: “What we are talking about is simply a single-payer insurance program, which means that you will have a card which says Medicare on it, you go to any doctor that you want, you will go to any hospital that you want.” He added that “you’re not paying any more premiums, you’re not paying any more copayments, you’re not paying any more deductibles.” In another context, he said the plan “would allow all Americans, regardless of their income, to get the health care they need when they need it.”
Not so fast. The experience of Canada, which follows the Sanders model, shows that single payer is not the best way to achieve the goal of access to timely care. Its single-payer program is universal, funded by taxpayers without deductibles or copayments, and excludes premiums for most users. Objective measures of performance show it’s a comparatively expensive system whose results are mediocre—and sometimes very poor.
A Fraser Institute study published in November examined 28 universal health-care systems across 45 indicators of performance. After adjusting for differences in the proportion of seniors, Canada ranked among the top spenders—fourth-highest as a percentage of gross domestic product and 10th-highest per capita. Yet it had less medical resources available for patients and painfully long wait times for specialists. Canada ranked 26th out of 28 for number of physicians, 22nd out of 27 for MRI units, and 25th out of 26 for hospital beds.
In Commonwealth Fund data comparing 11 developed countries, Canada reported the most patients waiting more than four weeks for a specialist appointment (56%), vs. only 22% for Switzerland and 23% for the Netherlands, the top performers. The proportion of patients waiting more than four months for elective surgery was 18% for Canadians, 2% for the French and zero for Germans. Canada performed well on only five of the 12 indicators of clinical performance and quality included in the Fraser Institute’s study. Its performance on the other seven—including obstetric traumas and diabetes-related amputations—was poor or average.
Overall, Canada performs worse than other universal-coverage countries, particularly Switzerland, the Netherlands and Germany. Why? Unlike Canada’s single-payer system, the Swiss, Dutch and German systems rely on private insurers, whether nonprofit or for-profit. Government helps the needy make premium payments.
German enrollees can use a public system composed of 145 competing independent nonprofit “sickness funds” or buy insurance from 43 companies or nonprofits. In the Netherlands and Switzerland, residents must select a standard insurance package from private insurers, of which both countries have dozens.
Unlike the U.S., with Medicare and its massive trillion-dollar unfunded liabilities, these countries cannot pass unreimbursed current expenses onto future generations. If the expenses of private insurers exceed their revenues, they face bankruptcy.
The relatively successful universal health-care systems also rely on private hospitals and physicians. As of 2012, 42% of German hospitals were for-profit, almost all of them open to patients with public insurance. These regulated for-profit vendors can readily access private capital to fund medical innovations—unlike government-run systems, which need bureaucratic approval to use tax revenue.
Consumers and the private sector drive the health-care systems in these countries, which accomplish exactly what Mr. Sanders and his supporters say they want—universal coverage, controlled costs, high quality and ready access. In contrast, Canada’s experience shows the dangers of the Medicare for All model.
Ms. Herzlinger is a professor at Harvard Business School. Mr. Barua is associate director of the Fraser Institute’s Centre for Health Policy Studies.
"It is only with the heart that one can see rightly; what is essential is invisible to the eye."
--Antoine de Saint-Exupery
"Things fall apart; the centre cannot hold."
--Yeats
“True, we [lawyers] build no bridges. We raise no towers. We construct no engines. We paint no pictures - unless as amateurs for our own principal amusement. There is little of all that we do which the eye of man can see. But we smooth out difficulties; we relieve stress; we correct mistakes; we take up other men's burdens and by our efforts we make possible the peaceful life of men in a peaceful state.”
--John W. Davis, founder of Davis Polk & Wardwell
The more I read the more I think that no one has a perfect system, and there are many superior elements in various systems. What's also clear to me is that what we have one is nowhere near the best considering comprehensive coverage, costs overall, administrative costs and quality of care across the board.
Is it possible that we could ever redesign our system where we best meld the superior options, put aside what's best for me or particular groups (users and providers) and politics? I think we'd come up with something much different. That's the public discussion I'd like to see, and not just the products of studies. Can we agree that our system needs fixing, and in a big way? Is that all wishful thinking, a distraction?
I don't believe that "Medicare For All" is better than a well managed private healthcare system.
The problem is that the the system we have now is not well managed, and there isn't any incentive outside of a government takeover to fix it.
And even those of us who work for the government don’t have equal benefits.
All local and state employees, for the most part, are on PEHP, but depending on who you work for that’s different.
I have 0 choices. I am forced to take a high deductible health plan. There’s one plan, period.
My wife who works for the state has multiple choices, one of which is my high deductible plan, but her’s has different deductibles and limits.
It’s ridiculous
Sent from my iPhone using Tapatalk Pro
This is sort of a cherry pick of ideas from different systems, with misleading information tossed in. Example: the piece mostly criticizes the Canadian model, but points out 42% of German hospitals are private and can therefore access private capital. Well, in Canada, 100% of the hospitals can access private capital, as the Canadian model is single *payer*, with the provision of healthcare being private. The UK model is actually the one this point needs to attack.
Germany, Switzerland, the Netherlands and Europe in general is much more likely to regulate a major cost component in our system: the horrific effects of fast food and soda. In other words, the US could never achieve the results of these nations, regardless of the healthcare systems they have. Some Americans would be brandishing their AR-15s if anyone suggested the Super Size offering of Diet Coke should be regulated.
Ironically, the main idea this article represents - using private insurance and mandates - is EXACTLY the approach the Heritage Foundation / RomneyCare / ObamaCare takes, but mandates are under a frontal assault, here. Step One here should be to fix the problems with Obamacare and work from there.
The Heritage Foundation plan is a long ways from Romneycare in Mass., and even farther away from the ACÁ. Here’s how it is supposed to work. Stuart Butler, a Heritage healthcare guy, proposed a voucher system. Employers would give their employees a voucher to spend on whatever health plan they wanted. Plans would compete each year to be the employees’ choice. Employees could spend more than their voucher’s amount, or less and keep the difference. There was a healthcare savings account, a provision for self-employed people and something like a generous version of Medicaid for the lowest incomes; they could get a voucher too, if they wanted one. (I’ve forgotten those details.)
This is where the mandate came in, because that system wouldn’t work without one. The Heritage concept would never fly politically (unless a single party controlled the government with a filibuster-proof majority and rammed it through, which we have seen recently and which predictably produced deeply flawed and controversial policy). But it did have some interesting ideas.
I actually support an individual mandate. It’s apparently unconstitutional, however, unless the Supreme Court finds it is a tax.
I like the Swiss model a lot, but Switzerland a small country, geographically and in terms of population, and the Swiss people are culturally much more inclined to follow rules then we rambunctious Americans are. I am not sure it would work here. Politically, the Swiss system constrains personal liberty, which the right would oppose; and it does not provide free healthcare on a broad basis, which is sacred to the left.
"It is only with the heart that one can see rightly; what is essential is invisible to the eye."
--Antoine de Saint-Exupery
"Things fall apart; the centre cannot hold."
--Yeats
“True, we [lawyers] build no bridges. We raise no towers. We construct no engines. We paint no pictures - unless as amateurs for our own principal amusement. There is little of all that we do which the eye of man can see. But we smooth out difficulties; we relieve stress; we correct mistakes; we take up other men's burdens and by our efforts we make possible the peaceful life of men in a peaceful state.”
--John W. Davis, founder of Davis Polk & Wardwell
Thanks for the insight into the Heritage proposal (circa HillaryCare, right?) Presumably the vouchers would be based on a community rating? Insurers compete for the healthiest customers?
When I worked in health insurance - in IT, granted - the individual market was seen as being highly desirable, because the premiums/margins were pretty high. (No way to establish a group rate based on track record of the employee group.)
With the Senate inching toward no filibuster, the barrier to sweeping change looks to get lower. If a moderate Dem got elected POTUS, with strong leadership in the Congress, a reasonable course toward a hybrid model could occur. If Sanders wins and the far left gets stronger, it could be highly disruptive. There's enough lobbyist money swirling around DC to head that off, I think, not to mention it would be an electoral kamikaze mission.
Until we can get a handle on diet & lifestyle (and Pharma, and defensive medicine, and the expansive costs prevalent throughout the system), any attempt at reform will struggle against reality.
Last edited by Ma'ake; 04-19-2019 at 11:03 AM.
This is core to any true healthcare reform. Anything that doesn't lower risk and improve utilization we are spinning our wheels. Then it is just a choice of being buried by taxes or private health insurance premiums.
This is actually why I am for high deductible plans with HSAs because people need to have an incentive to reduce their healthcare costs and that is only going to come with some skin in the game.
"Is there a generic equivalent to this drug?"
"If I choose between two procedures and the core difference is it takes me a week longer to recover but I save $30k let's do the cheaper..."
"If I drop 20lbs I can come off this blood pressure medication that is costing me $200/mo?"
There are soooooooo many instances of healthcare decisions that can make a difference in your care but save tens of thousands. Better personal health being at the top.
If you read Freakanomics you may remember the part about how realtors don't really act in your best interest and will persuade you to lower your asking price by tens of thousands of dollars because it only means a few hundred for them and they just want a quick commission. We have something similar in healthcare in that if the difference of certain types of treatment may be tens of thousands but only costs you hundreds if anything, we also don't make the best decisions.
Sent from my iPhone using Tapatalk
This doesn't change anything. If anything it makes it worse. Currently, companies can aggressively negotiate terms based on group rates. That goes away with shifting the choice to employees. Plus, the illusion of "choice" is just that: an illusion. In reality, there isn't much choice in the insurance market.
Under that old Heritage plan individuals would be free to take their voucher to whatever plan they liked best. The idea was to make the plans compete for each person's business. Interesting idea, on paper.
"It is only with the heart that one can see rightly; what is essential is invisible to the eye."
--Antoine de Saint-Exupery
"Things fall apart; the centre cannot hold."
--Yeats
“True, we [lawyers] build no bridges. We raise no towers. We construct no engines. We paint no pictures - unless as amateurs for our own principal amusement. There is little of all that we do which the eye of man can see. But we smooth out difficulties; we relieve stress; we correct mistakes; we take up other men's burdens and by our efforts we make possible the peaceful life of men in a peaceful state.”
--John W. Davis, founder of Davis Polk & Wardwell
I think the only way health care insurance will work in the USA, in the short term, might be the way Jenkins describes it here. Our hodge-podge system seems to be the only one that's politically feasible. Obamacare massively expanded Medicaid, and that's its primary achievement.
*****
ObamaCare Is Popular Because It Failed
Holman W. Jenkins, Jr.
April 26, 2019 6:20 p.m. ET.
Only corporate America can save the U.S. from drowning in wasteful health-care costs.
ObamaCare is finally popular with the American people according to a variety of polls, and it’s instructive to understand why. The doing is Donald Trump’s and the Republicans’, and not in a way that made ObamaCare a sensible program.
Thanks to their effective repeal of the individual mandate, nobody is forced any longer to buy ObamaCare or pay a tax penalty. ObamaCare’s user cohort now consists almost entirely of willing “buyers” who receive their coverage entirely or largely at taxpayer expense. It also consists of certain users who take advantage of the coverage for pre-existing conditions and stop paying once their condition has been treated.
So why is ObamaCare growing in popularity with the 94% of Americans who don’t use it? Because it’s there if they need it.
A lesson here is worth holding on to: The public wants a safety net if they are caught without health insurance. In the absence of a personal emergency, they prefer their existing arrangements, which for 68% of us means employer-provided health insurance or some other purely private arrangement.
In every larger aim, the Affordable Care Act has predictably failed. It was supposed to ramrod efficiency through the health-care marketplace. Instead, it has become just another inefficient program bringing subsidized medicine to one more arbitrarily defined subset of the population.
Donald Trump listens to his briefings, apparently, because he cut to the heart of the issue with a recent tweet pointing out that, for most people, ObamaCare was not “useful.” He’s right. For a family of four not benefiting from a subsidy, notes insurance industry veteran Bob Laszewski, a policy can cost $15,000 with a $7,000 deductible. In other words, “they have to pay $22,000 before they get anything.”
Nonetheless, this column once maintained that a reformed ObamaCare, with its now-defunct individual mandate and its half-impulse to confine handouts to the needy, was potentially a better program than the menagerie of programs we have now. ObamaCare, in theory, could replace them all, including Medicare and the tax giveaway for employer provided insurance.
Alas, the idea of sweeping health-care reform seems to have gone out with the Bill Clinton and George W. Bush administrations. Two obstacles stand in the way. Nothing says “I care” like promoting more health-care spending, so U.S. politicians are addicted to dishing out incentives for Americans to consume medical attention whether or not it does them any good.
Secondly, how to climb down from any existing set of subsidies without provoking some vital bloc of voters has proved the unsolvable equation of America’s gridlocked politics. Notice that even the GOP’s “repeal and replace” campaign devolved into trying to repeal the funding for ObamaCare (e.g., the medical-device tax) without repealing the benefits.
Our destination is clear. In the future, there will be one gold-plated health-care system for the rich and workers in high tax brackets. There will be another system for those who depend on a proliferating array of government programs. They can read their future in the latest report of the Trustees of Social Security and Medicare, out this past week. These giant budget sucks are rapidly outrunning their dedicated funding sources. Soon they will be openly competing with every other federal priority for nonexistent tax dollars, including those that the Democratic presidential candidates would like to spend on free college and Medicare for all.
If you depend on government-provided health care, the upshot is inevitable: longer waiting lists, rising copays and steeper deductibles as Washington struggles to pay for the medical procedures it has promised you regardless of whether these procedures leave you better off.
Should we abandon hope? No. The saving grace of our funky system is the giant tax incentive it gives employers to preserve profits by figuring out which medical treatments actually keep their employees healthy and which don’t. This shouldn’t be corporate America’s job, but it is. It’s no joke to say many U.S. businesses have more to gain from controlling health-care costs than they do from running their own operations better.
Hence the vaunted new health-care alliance created by Amazon CEO Jeff Bezos, J.P. Morgan CEO Jamie Dimon and Berkshire Hathaway CEO Warren Buffett. It’s called “Haven.” If it succeeds, it will do so by figuring out which half (a plausible estimate) of America’s medical spending is a complete waste of money.
Appeared in the April 27, 2019, print edition.
"It is only with the heart that one can see rightly; what is essential is invisible to the eye."
--Antoine de Saint-Exupery
"Things fall apart; the centre cannot hold."
--Yeats
“True, we [lawyers] build no bridges. We raise no towers. We construct no engines. We paint no pictures - unless as amateurs for our own principal amusement. There is little of all that we do which the eye of man can see. But we smooth out difficulties; we relieve stress; we correct mistakes; we take up other men's burdens and by our efforts we make possible the peaceful life of men in a peaceful state.”
--John W. Davis, founder of Davis Polk & Wardwell
Obamacare has been attacked so ferociously, for so long, and has been significantly dismantled... it's pretty amazing it still exists. The author is right that its popularity exposes a primal fear among many that they may actually have to depend on it... which is better than being shoved off the ship in the dead of night, forced to sell their homes. But Obamacare, at best, was only a start, only addressed the coverage part of the equation.
The Bezos / Dimon / Buffett initiative, along with whatever Walmart comes up with, are very interesting / promising efforts to attack another core problem, which is healthcare provision costs. If they're successful, it will be a huge blow to those who get into healthcare to become Millionaires & Billionaires. But it will be a private effort, the "creative destruction" that has been the hallmark of economic progress in so many other areas of our economy.
If these private efforts crush the resistant cost bunkers that make healthcare reform extremely difficult, it wont be Big Brother that does it. We would see physicians bailout out of the profession in droves - just like if a single payer system emerged - but I would argue that BMW-driving physicians and Big Pharma researchers are a huge part of the existing problem.
Airline captains are no longer in the top tier of the American worker caste system, they're no longer in the stratosphere with lawyers and physicians... but they're still around, air travel has become affordable for many for whom it was a luxury before, it's still safer to fly than drive. All the doomsday talk of the airline system falling apart under low wages and airlines taking shortcuts on safety hasn't happened.
Last edited by Ma'ake; 04-28-2019 at 08:19 AM.
Why has Medicare endured for going on 60 years? To me the biggest reason is that it was truly bipartisan. More than half the Republicans in the House voted for it, and almost half the Republican senators did also.
In contrast, Obamacare was rammed through by a once-in-a-lifetime filibuster-proof Democratic majority, without a single opposing party vote. We can argue all day about whose fault that is, but it has proven to be the biggest problem with that law.
"It is only with the heart that one can see rightly; what is essential is invisible to the eye."
--Antoine de Saint-Exupery
"Things fall apart; the centre cannot hold."
--Yeats
“True, we [lawyers] build no bridges. We raise no towers. We construct no engines. We paint no pictures - unless as amateurs for our own principal amusement. There is little of all that we do which the eye of man can see. But we smooth out difficulties; we relieve stress; we correct mistakes; we take up other men's burdens and by our efforts we make possible the peaceful life of men in a peaceful state.”
--John W. Davis, founder of Davis Polk & Wardwell
Medicare (and Medicaid) were passed when there was more bipartisanship & semblance of common national interest, in Congress. I was struck during the Obamacare creation that Republicans turned on two of their own ideas:
1. The states are laboratories of ideas to be tried, and if the policy/program was successful, it could be used nationally.
2. The program thrown under the bus was Republican initiated & bipartisan, Romney's bipartisan healthcare plan in Massachusetts. Actually, RomneyCare became a reason Republicans opposed him in 2012 - he was too close to Obamacare, from a program genealogy standpoint. His own architect for RomneyCare was hired to help put together Obamacare.
Ma'ake, I think the seeds of Obamacare were in Romneycare, but any similarities between the two are a lot more subtle than you suggest. Romney himself never proposed the Massachusetts model for the USA as a whole. I heard him say many times that his brainchild "was right -- for Massachusetts." Anyway, here's a short analysis by Avik Roy, a very conservative health care expert. He's not supportive of Romney care in this piece at all, and he's not 100% right about everything, IMO, but he does point out some subtleties:
How the Heritage Foundation, a Conservative Think Tank, Promoted the Individual Mandate
https://www.forbes.com/sites/theapot.../#2125aafa6187
"It is only with the heart that one can see rightly; what is essential is invisible to the eye."
--Antoine de Saint-Exupery
"Things fall apart; the centre cannot hold."
--Yeats
“True, we [lawyers] build no bridges. We raise no towers. We construct no engines. We paint no pictures - unless as amateurs for our own principal amusement. There is little of all that we do which the eye of man can see. But we smooth out difficulties; we relieve stress; we correct mistakes; we take up other men's burdens and by our efforts we make possible the peaceful life of men in a peaceful state.”
--John W. Davis, founder of Davis Polk & Wardwell
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