You may be getting a rebate check from your health insurance provider, courtesy of the Affordable Care Act, also called “Obamacare.” Odds of your being one of the rebate recipients are about one in four, maybe a little better. The average amount of the rebate is around $76, although a very few will be as high as $500. Some of those checks already are in the mail.

The ACA provides that health insurance companies must spend at least 80 percent of the premiums they receive on medical care. And for large group plans, that’s 85 percent. If they fail, they must rebate the difference back to policy holders. The Kaiser Family Foundation estimates that “consumers and businesses are expected to receive an estimated $1.3 billion by this August.”

The insurance industry grumbles that the rebate requirement is likely to increase their costs and cause an increase in premiums. The Kaiser Foundation says that’s nonsense. It’s more likely to cause insurers to think twice before asking for a premium hike. In fact, it may already have saved you some money.

“The presence of these thresholds and the corresponding rebate requirement have provided an incentive for insurers to seek lower premium increases than they would have otherwise,” a Kaiser report says. “This ’sentinel’ effect on premiums has likely produced more savings for consumers and employers than the rebates themselves.”

Keeping health insurance affordable is a huge problem in the United States. Insurance costs are draining businesses and probably contributing to unemployment. It’s also a problem for individuals, especially those with devastating health problems such as mesothelioma.

The political world is buzzing because the Obama Administration insists that insurance companies inform customers why they are getting rebates. The checks must be accompanies by a letter saying the rebates are required by the Affordable Care Act.

The Administration may be frustrated by the fact that polls show the ACA remains unpopular. However, when polled about individual provisions of the law, people say they are in favor of most of them.

For example, pols show most people agree that insurance companies should spend more of the money they receive in premiums on health care than on administration and marketing. They agree that people should not be denied coverage because of a pre-existing condition. They want the government to help poor people get health care.

Many people are confused about what’s in “Obamacare.” That’s partly because the law’s many parts are going into effect at different times.  This is the first round of rebate checks, for example. A lot of the major provisions are scheduled to go into effect in 2014.

The Administration hopes that people will like the law once they see that it really will benefit them or someone they know. And that’s why they want to know that the rebate checks are a result of the ACA.

We’ve been talking about the claims that doctors are attracted to states that have enacted “tort reform” laws. A close look at the data shows that this is a myth.

“Tort reform” refers to a broad movement begun in the 1980s by the tobacco industry. Tort reform ideologues blame personal injury lawsuits for all kinds of ills, from a weak economy and business failures to exploding health care costs. Well-funded lobbying efforts have targeted legislatures in every state. And by now only a handful of states have not gotten on the “tort reform” bandwagon.

So, in return for the false promises of more doctors, lower health care costs, and even more jobs, state legislators are trading away their citizens’ rights to sue for damages.

State after state have passed laws that put caps on what damages a plaintiff might receive, no matter how badly he or she was injured. They have also made it more difficult for some kinds of suits to be brought to court at all. This has impacted people with a wide variety of injuries, from homeowners ripped off by crooked construction contractors to retired factory workers dying from mesothelioma because they were exposed to asbestos on their jobs.

But some of the most elaborate claims have been made about one particular kind of tort, which is medical malpractice. It is an article of faith in some quarters that malpractice reform all by itself would solve most of America’s health care problems. Many states have given their doctors an extraordinary amount of protection from malpractice.

In Texas, for example, an emergency room physician can be sued only if the injured patient can prove the doctor harmed him intentionally. Since a doctor’s intentions are nearly impossible to prove, Texas ER doctors are virtually free of malpractice liability.

Back in 1999 the Institute of Medicine estimated by 98,000 Americans die every year from preventable medical error. More recent estimates have put that number at close to 200,000. Many more errors have left patients with permanent injuries.

For example, a 53-year-old Texas man named David Fitzgerald went into the hospital for a simple ulcer operation. He developed an infection that was not treated properly. The infection spread to his limbs, and both arms and both legs were amputated to save his life. However, the rigid Texas “tort reform” laws prevented him from getting a big enough damage award to pay for the care he will require for the rest of his life.

A website called 98000reasons.org documents more cases. For example, 29-year-old Quanisha Scott developed a hematoma after surgery to remove a goiter. Her complaints went unheeded and unreported. Ms. Scott went into respiratory arrest, suffered brain damage, and is now totally dependent on her mother for care.

A schoolteacher named Merlyna Adams sought help for a kidney stone and received such shoddy treatment she became infected. She lost both hands and both legs below the knee.

In the minds of “tort reform” fanatics people like David Fitzgerald, Quanisha Scott, and Merlyna Adams do not exist. They will tell you that people who sue their doctors are “greedy” people looking for “jackpot” settlements from a jury. There is conflicting data and wide disagreement about how many malpractice suits really are frivolous. But by now it’s clear that giving away the right to sue isn’t solving our health care problems.

The last post debunked the fairy tale that malpractice reform is a sure cure for doctor shortages. Lets look for a minute at where doctor shortages exist in the U.S. and what’s really causing them.

Wall Street Wire looked at data from the American Medical Association, the U.S. Census Bureau, the Kaiser Family Foundation, and other sources to determine which states had the biggest doctor shortage problem. A look at this chart shows no correlation between shortages and “tort reform,” one way or another.

Several of the states in the “top” ten list of states with the biggest shortages — notably Georgia (#2), Mississippi (#4), and Texas (#6) have “malpractice reform” laws in place that were supposed to solve the shortage problem, but clearly haven’t.

Just three years ago Arizona Senator John Kyl was sending out press releases crowing about how Arizona’s malpractice reform laws were solving that state’s physician shortage, and complaining that the “president and congressional Democrats have not asked anything of personal-injury trial lawyers.”

According to Wall Street Wire, Arizona today has the worst physician shortage problem in the nation. It’s Number One! Or, it’s Number 50!, depending on whether you are counting “worsts” or “bests.”

In state after state, lobbyists from the insurance industry and other special interest groups are telling legislators that malpractice reform, often within a bigger “tort reform” package, is the silver bullet that will solve their physician shortages. And you can find politicians and industry spokespeople claiming many spectacular results. But when you look at actual numbers, the results just aren’t there.

The same thing goes for claims that “tort reform” will attract industry to a state and grow jobs. This is something one hears over and over again, yet the supporting evidence is remarkably weak. The fact is that legislators are trading away your right to sue for damages in return for promises that don’t come true. And the people who suffer most are the ones with the most damage, such as those suffering mesothelioma cancer from exposure to asbestos.

So malpractice reform doesn’t make that much difference in how many doctors are practicing medicine in any one state. What are states really doing wrong, or right, to be sure there are enough doctors to take care of its citizens?

When people talk about physician shortages, they are usually looking at the ratio of doctors to patients. The standard measure is the number of doctors per one thousand people living in a particular area. Sometimes a state has rapid population growth that will skew its doctor-to-patient ratio for a while. That may be part of Arizona’s problem.

A more important factor probably is the number of physician internships and residencies in a state. As you probably know, after medical school aspiring doctors work as interns and residents under the supervision of licensed physicians. Many doctors begin practice near where they went through their medical residencies.

These residencies usually are partly funded by state taxes, and as states have cut their budgets they have trimmed residencies. This appears to be one reason why Texas is continuing to struggle with physician shortages. Texas is home to many first-rate medical schools, but increasing numbers of medical school grads find they must go to another state for their residencies. And usually they don’t come back, in spite of Texas having reformed its malpractice laws every which way it can.

One aspect of physician shortages is that populations need more general practice doctors than they need, say, plastic surgeons. But most medical school graduates go out into the world burdened by whopping student loan debts. This inspires a disproportionate number of them to go into specialties that will give them higher incomes than GPs can make.

In short, there are many reasons why some parts of the country have more doctors than other parts. Compared to those other factors, a state’s malpractice laws make a very minor impact.

It’s one of those things that “everybody knows” — there would be more doctors practicing medicine if it weren’t for all those pesky malpractice suits. And “everybody knows” a sure way to attract doctors to your state is to change the laws to protect doctors from being sued.

Yes, it seems “everybody knows” that. But a new study of tort reform in Texas says it’s not true. Here is the abstract:

“Does state tort reform affect physician supply? Tort reformers certainly believe so. Before Texas adopted tort reform in 2003, proponents claimed that physicians were deserting Texas in droves. After tort reform was enacted, proponents claimed there had been a dramatic increase in physicians moving to Texas due to the improved liability climate. We find no evidence to support either claim. Physician supply was not measurably stunted prior to reform, and did not measurably improve after reform. This is true whether one looks at all patient care physicians in Texas or at high-malpractice-risk specialties.”

In many parts of the country, access to medical care is hampered by physician shortages. This problem is especially acute in poor and rural areas. A few years ago, tort reform advocates began going around to state legislatures and telling them that physician-friendly malpractice laws would attract physicians to their states. By now enough time has gone by that we ought to be seeing results. But there are no results. That hasn’t stopped the lobbyists from insurance companies and physicians organizations to continue to make the argument, however.

Legislators are trading away the rights of citizens to take grievances to court in return for false promises. Any of us might be injured by a doctor, or by a product, or in an unsafe workplace. The most injured, such as people who suffer mesothelioma from exposure to asbestos, really need what damages they might receive to take care of themselves and their families.

The fairy tales about all those grateful doctors flocking to Texas just won’t die. Last year when he was running for the Republican presidential nomination, Texas Governor Rick Perry claimed that his 2003 tort reform law had attracted more than 20,000 new physicians to Texas.  Other Texas state agencies will tell you doctors are breaking down the doors trying to practice in Texas. Spokespeople for the insurance industry and physicians organization just love Texas tort reform and say it’s the best thing since cell phones.

The the authors of the study — professors David Hyman (Illinois), Charles Silver (Texas), and Bernard Black (Northwestern) have looked at the actual numbers, and they say these claims are just flat-out not true.

“Using active, direct patient-care (DPC) physicians per 100,000 population as a measure, we found no evidence of a pre-2003 decline in access to care, and no evidence of a post-reform improvement. To the contrary, the rate of increase in Texas DPC physicians per capita was lower after reform.”

The full study, “Does Tort Reform Affect Physician Supply? Evidence from Texas,” can be downloaded for free in PDF format.

Right now, the odds that the Affordable Care Act (ACA) will survive long enough to be fully implemented seem pretty long. Even if the Supreme Court doesn’t strike it down as unconstitutional this summer, a Republican victory in November would probably lead to its repeal.

The ACA, also called “Obamacare,” is not very popular according to polls. However, polls also show that many Americans don’t understand the complex law. Voters who support anti-Obamacare candidates may not like the results if their candidates win.

Seniors with serious health issues such as mesothelioma cancer are especially vulnerable to a loss of medical care.  One of the trustees of the Medicare warns that if “Obamacare” is struck down or repealed, the effect on Medicare could be devastating.

The trustee, economist and former Urban Institute President Robert Reischauer, spoke at the American Enterprise Institute this week. He said that partly as a result of “Obamacare,” the growth of health care cost has slowed dramatically, and the entire health care system seems to be moving in a more sustainable direction. But if the ACA is struck down or repealed, Reischauer said, those improvements would be reversed.

More critically, Medicare payments would be thrown into chaos. The ACA rewrote the laws that determine how health care providers are reimbursed. If the ACA is nullified, two years of policy and processes will be canceled. Sara Rosenbaum, a professor of health law and policy at George Washington University, said the entire health care system could come to a halt.

“You have agencies sitting on two years of policies that are up in smoke,” she said. “Hospitals might not get paid. Nursing homes might not get paid. Doctors might not get paid. Changes in coverage that have begun to take effect for the elderly, closing the doughnut hole might not happen. We don’t know.”

And because these same hospitals and nursing homes also serve non-Medicare patients, all patients could be affected.

The “doughtnut hole” is a gap in Medicare prescription drug coverage that causes some seniors to pay thousands of dollars out of pocket for their medicines. The ACA has partly closed the hole, and if it isn’t struck down it will close the entire hole in a few years. If the ACA is struck down, the “hole” will open up again.

This is not necessarily an argument for preserving the ACA as it is. However, if any part of it is repealed, there needs to be a law already written to replace it. Otherwise, the entire U.S. medical system could find itself in the Twilight Zone.

Tom Billet, a senior benefits consultant with Towers Watson, warns that the nation’s employers may not be prepared for the consequences if Obamacare suddenly disappears. “Employers had been the major force driving health care change in this country up until the passage of health reform,” he said. “If Obamacare disappears … we go back to square one. We still have a major problem in this country with very expensive health care.”

It’s a near certainty that Mitt Romney, former governor of Massachusetts, will be the Republican presidential nominee. Like his rival Republican candidates, Romney has adopted “repeal and replace” as his answer to “Obamacare,” or the Affordable Care Act (ACA) passed by Congress in 2010. But with what would he replace it?

The question is complicated by the fact that the ACA was modeled after a health care reform law championed by Romney while he was governor of Massachusetts. And the Massachusetts law was partly based on ideas generated by the conservative Heritage Foundation, which thought “Romneycare” was just dandy until a Democratic President borrowed its provisions for his own legislation.

Since then, Mr. Romney and the Heritage folks have raged against their own ideas and painted the ACA as the worst thing that’s happened to America since the British invasion of 1812. And since Romney has repudiated his own record in Massachusetts — in spite of the fact that his health care law is popular there — we can’t go by his record on health care to know what he might do as president.

Politicians of both parties will paint their opposition as dangerous radicals whose ideas will hurt America. It’s important for voters to look at the details of what candidates propose and decide for themselves whose ideas are more radical. This is especially true for those with life-threatening conditions such as mesothelioma, because health care policies can be life or death for them.

In the Los Angeles Times, Noam N. Levey writes that Mr. Romney could replace the ACA with something much more revolutionary. “Mitt Romney has turned to proposals that could alter the way hundreds of millions of Americans get their medical insurance,” Levey writes.

The centerpiece of Romney’s plan, Levey says, is to eliminate health insurance as an employment benefit. Instead, he would give Americans who buy their own insurance a tax break to help pay for it. If most Americans are buying their own insurance on the private market, the theory goes, competition will drive down prices and give people more choices.

Without a mandate for people to buy insurance, however, those insurance companies can’t be forced to take people with pre-existing conditions. So Romney’s approach would also be riskier and could possibly leave even more Americans without health insurance than is true now.

By contrast, the Massachusetts plan that Romney repudiated has reduced the number of Massachusetts citizens without health insurance. It worked, in other words. And when the Affordable Care Act goes into more effect in 2014, it is believed at least 30 million Americans will be able to obtain insurance who don’t have it now.

The fact is, there is no place on Planet Earth in which most people are getting health care paid for by individual policies purchased from for-profit, private insurance companies. Most industrialized countries have some kind of taxpayer-funded program that provides most health care for citizens. In a few countries private insurance companies are required to sell a basic insurance package at cost; insurers can make a profit only on supplemental insurance products. Only in the United States are private, for-profit insurance companies paying for most health care.

Further, Romney has proposed privatizing Medicare. He also wants to scrap Medicaid in favor of giving block grants to states to provide health care for the very poor. Many experts warn that this could result in seniors paying a lot more out-of-pocket for the health care, and the very poor getting even less health care than they are now.

We should get more details as the campaign progresses. It’s important for all of us to be paying attention.

Will Rogers used to say “All I know is what I read in the papers.” These days he might be saying “All I know is what I see on cable television.” Either way, since most of us are too busy to investigate current events ourselves, we depend on news media to keep us informed.

Unfortunately, what we read or hear may be very misleading. Here is a recent example:

Earlier this month, a Medicare and Social Security trustee named Chuck Blahous issued an analysis of the Affordable Care Act, called “Obamacare.” Blahous claimed the law would add between $340 billion to $540 billion to the deficit in the next decade.

Blahous’s figures contradicted the conclusions of the Congressional Budget Office, that the ACA could decrease the deficit by billions, not add to it. Blahous said that the CBO was wrong because it had counted cost reductions twice.

Blahous’s paper was published by the conservative Mercatus Institute and distributed to news editors around the nation. Soon newspapers and television and radio news were reporting that “Obamacare” will cost billions more than the Congressional Budget Office had said it would.

The nation’s wobbly health care system and stubbornly growing federal deficit are both worrisome for Americans. This is true whether they are healthy or have serious illnesses such as mesothelioma or other cancers. Must helping people get health care now leave the nation with a crippling deficit?

People who support the President’s health care reform law soon cried foul. Blahous, not the CBO, was playing fast and loose with numbers, they said. In particular, he is playing fast and loose with Medicare figures.

The Affordable Care Act calls for new spending to provide medical insurance for those who can’t get insurance now because they are too poor or too sick. To pay for that, the ACA raises some taxes and also makes some changes in the Medicare program that will save money without cutting benefits.  The CBO projects that the cost savings and new revenue combined will more than pay for the new spending, and so the ACA should reduce the deficit, not add to it.

According to columnist Jonathan Chait, Blahous based his contradictory conclusion on the assumption that without the Affordable Care Act, Medicare will run out of trust fund money in a few years. Since Medicare can’t spend money it doesn’t have, without the ACA Medicare would be forced to drastically cut benefits. So, the cost savings in ACA don’t count, Blahous said, because that is money a mostly defunct Medicare program would not have spent, anyway.

In other words, Blahous figured that without the ACA, we would have the same amount of spending cuts (since Medicare would be largely kaput) but none of the new spending. Blahous then arrived at his calculation of $340 billion to $540 billion added to the deficit by counting the cost of new spending alone, without the cost savings built into ACA to offset new spending.

Unfortunately, people reading newspaper headlines or listening to television or radio news don’t hear how Blahous arrived at his conclusion. They just hear that some expert said Obamacare will add billions to the deficit, which makes Obamacare sound like a terrible idea.

Don’t believe everything you read in the papers.

Recently the American Legislative Exchange Council, or ALEC. made news when four of its major corporate members — Kraft, Coca-cola, McDonald’s, and Intuit — announced they were dropping out. The Gates Foundation, a private philanthropic organization run by Bill and Melinda Gates, announced it would no longer award grants to ALEC.

But what is ALEC, and why are corporations leaving it?

ALEC calls itself a  “membership association of state legislators.” However, almost all of its funds come from corporate sponsors, not legislator member dues. Since its founding in 1973, ALEC has helped to get bills favoring conservative causes passed in state legislatures. But it is not exactly a lobbying group. Here’s how it works:

Let’s say you are a widget manufacturer, and you want state laws changed that will make your company more profitable. For example, you might want looser environmental regulations, or you want laws that shield you from liability if one of your widgets hurts somebody.

If your company is a member of ALEC, you can write your own model bills and persuade the state lawmakers who are also members to introduce those bills in their state congresses. The lawmakers often are invited to conferences at luxury resorts where an ALEC team hands them packets of model bills and teaches them how to sell the bills to the folks back home.

Adam Sorensen wrote in Time magazine, “Think of ALEC’s prepackaged and prelawyered legislation as Swanson TV dinners: all you need is a majority vote to reheat it, and it’s ready to serve.”

Now, there is nothing secret or illegal about this. But recently ALEC has been a little too successful. People started to notice that many identical, as in word for word, bills were being introduced in the nation’s statehouses. And many of these bills were controversial.

For example, ALEC bills have stripped unions of collective bargaining rights. Others have established strict voter ID requirements that may stop many citizens from being able to vote.

ALEC is a major source of the many “tort reform” laws passed by state legislatures in recent years. These laws make it harder for citizens to sue and collect damages when they are harmed by a faulty product or medical malpractice. These laws punish the most severely injured people by capping the amount of damages they can receive, regardless of the nature of their injuries. For example, people suffering from mesothelioma, caused by exposure to asbestos, may not be able to collect enough damages to pay medical bills and provide for families.

Recently the governor of Minnesota vetoed four ALEC-written tort reform bills. “I’ve found that Minnesotans do not want their laws written by the lobbyists of big corporations,” Gov. Dayton said.

No one has accused Kraft or McDonald’s of trying to suppress voting rights. But threatened boycotts against corporate members of ALEC persuaded some CEOs that membership in ALEC wasn’t worth risking the good will of the public.

A budget passed by the U.S. House of Representatives last week made headlines this week, when {resident Obama made a speech blasting the budget as radical and unworkable.  After discussing proposed changes to Medicare and Medicaid, he said,

“The net result is that our country will end up spending more on health care, and the only reason the government will save any money — it won’t be on our books — is because we’ve shifted it to seniors. They’ll bear more of the costs themselves. It’s a bad idea, and it will ultimately end Medicare as we know it.”

Congressman Paul Ryan of Wisconsin, the chief author of the budget, was campaigning in Wisconsin with presidential candidate Mitt Romney. He responded to the President’s speech by calling it “desperate and demagogic.”

Political pundits are saying that Paul Ryan is a possible candidate to run for vice president on Romney’s ticket. If this is the case, we’re likely to hear a lot more about the budget during the campaign.

It’s going to be critically important for American voters to tune out all the negative advertisement and boastful claims and look closely at what candidates are proposing. Remember, sometimes when a politician says he’s going to get government off your back, what he really means is that he plans to cut all the government programs that are doing you any good.

Politicians of both parties say they want to save Medicare and prevent it from running out of money. The Affordable Care Act, also called “Obamacare,” has a number of measures designed to cut Medicare costs without cutting benefits or making other drastic changes to the program. How well these will work we have yet to see, of course.

But Republicans have gotten behind the idea that the way to save Medicare is to privatize it, meaning turning most of its administration over to private insurance companies. Is that really a good idea?

Medicare came into existence almost 50 years ago because growing numbers of seniors lacked health insurance. And that’s because the health challenges of the senior years make covering seniors unprofitable for insurance companies. Some dangerous diseases, such as mesothelioma, are far more likely to be diagnosed in older people than younger people.

When he ran for President in 1960, John F. Kennedy promised to help elderly people “who cannot pay their doctor bills.”  He didn’t live to see Medicare become law; it would be signed into law by Lyndon Johnson in 1965.

This means it has been almost 50 years since Americans heard much about seniors who couldn’t pay their doctor bills. After all this time many Americans probably can’t imagine what that even means. But it was because the private insurance companies failed to provide insurance to seniors that Medicare was created. A lot of people don’t remember that.

The Republican plans called for the federal government to provide “premium support,” meaning that it would pay for all or part of the insurance premiums. The theory is that private insurance companies will do a more efficient job than the government of administering the program and holding down cost. However, that was also the theory behind the old Medicare+Choice program as well as Medicare Advantage, which replaced it. Both programs revealed that private insurance companies have more overhead than the government, and and it has cost taxpayers abut 15 percent more to pay for a Medicare Advantage benefit than the same benefit under regular Medicare.

The bottom line is that nobody has a plan for saving Medicare that is guaranteed to work. The November election probably will determine whether the federal government will attempt to save the program as it is or radically overhaul it.

Most of us don’t follow how Congress plans to spend the taxpayers’ money. Federal budgets are complicated, and we have our own budgets to worry about. However, federal budgets make a big difference in our lives, and the time to understand what a budget might do to yours is before it is passed.

Last week the U.S. House of Representatives passed another budget authored by Rep. Paul Ryan, Republican of Wisconsin. Washington watchers say the budget has no hope of passing in the Senate.

However, the plan laid out in the budget is endorsed by most of the Republican party and also by Mitt Romney, currently the front-runner for the Republican presidential nomination. If Republicans re-take the Senate in November, something like the Ryan budget is likely to pass in both houses next year. And if Mr. Romney is president, he is likely to sign it.

The Ryan budget proposes big changes for Medicare, so let’s talk about that. If you or a loved one are on Medicare, or you expect to be on it someday (who doesn’t?), you need to know about these changes. This is especially true for those with life-threatening conditions such as mesothelioma, which usually is diagnosed in people over the age of 50.

What happens if it becomes law? If you already are on Medicare, probably nothing. Younger people won’t get the same Medicare program when they enroll, however.

First, the eligibility age will be raised gradually to age 67. Then, beginning in 2023, as people turn 67 they will be given an option to stay on “regular” Medicare or enter the private insurance market. The government would pay “premium support” (some call it a voucher) for the private plan.

That may not sound so bad, but there’s a catch. The government will pay no more than the amount of the least expensive policy available to you. If you want to choose another option, you will have to make up the difference out of your own pocket. This is true if you stay on “regular” Medicare; if a private plan is less expensive, you will have to pay the difference to keep Medicare.

In theory, if you find a plan that is less expensive than the amount of the “premium support” you could pocket the difference. The chances this would ever happen are slim, however, because Ryan’s plan also calls for holding Medicare spending far below current projections for health care costs.

This means that to make up the difference the program will either have to cut benefits, or else seniors will be paying more and more over time to stay insured.

Republicans have not been secret about their wish to privatize Medicare, Social Security, and many other programs. Last year Ryan proposed a budget that would have simply privatized Medicare and forced all seniors into the private market. Public opinion was against the plan, so this year’s plan allows politicians to say they are saving traditional fee-for-service Medicare. However, the plan is set up to potentially encourage people to drop Medicare and take a private plan