Oh, My God -- So This is Why Health Care Spending is So High! (TPM Cafe)

[On the Road]

Silliness of "Market-Based" Health Care Reform
By Nathan Newman

The bright idea from the right wing is to give individuals incentives to save money on health care, thereby driving down costs and freeing up money for lower costs and/or greater coverage. Sounds like a nice idea and would make sense if average users of health care had much effect on health care costs. But they don't. See this table:

Share of HC       Cumu Share of 
  Spenders         Med Spendg
  Top 1%         30%
  Top 5%         58%
  Top 10%        72%
  Top 30%        90%

So 70% of the population use just 10% of health care resources-- and most marginal incentives such as copays will largely be wasted in trying to effect their behavior. And they are largely wasted on those maxing out health care use, since the copays are so minor compared to the larger health care costs they take on.

http://www.tpmcafe.com/blog/coffeehouse/2007/mar/11/silliness_of_market_based_health_care_reform

I'm kind stunned by this, because it implies that the top 1% spend over 200 times per person what the average is for the bottom 70%. But here's TPM's source (bottom), and the original study. It certainly does place the health care debate in a different light.

[K8-EEE]

1. K&R -- I'm also totally amazed!!

Wow....just wow.

[ComerPerro]

2. not so suprising when you consider distribution of wealth in the US,

factor in costs of Health Insurance or no coverage at all for the lower half of the population, while the top 1% probably visit medical specialists more frequently and at higher rates, more readily have procedures done (because they can afford them), pay more for these procedures (because they are going to the top speicalists in the nation at times), as well as the costs associated with cosmetic or elective procedures.

Its sorta like the talking point RWers use when they want to shock someone into feeling sorry for the tax "burden" that the rich must "suffer". They will show you charts detailing how the top one percent pays thirty percent of the taxes, or whatever, and stress how unfair it is. But, really, when you consider how much money this group holds, its astonishing that they don't pay more than they do. The distribution of wealth is that out of whack.


Not to diminish your point. And I am not trying to suggest you are trying to generate sympathy for the rich.

In fact, you have brought up a fantastic point. Bush wants to keep the costs down in the ways he suggests specifically because his base, the rich, have the most to gain.

[Selatius]

3. I wonder what Dick Cheney spends trying to keep his aging, decayed, ruined body running.

All that pure hate and greed coursing through one's body must have a corrosive effect on the body.

[undergroundpanther]

9. All the money in the world

Won't stop death. Alot of rich pigs think they'll live forever and that makes them a cancer.Death will get Cheney someday.
because his fucking flesh can't live forever no matter how pampered indulged and patched up he is.
Maybe he clings to life and sucks it out of everyone else because he has no soul inside.Maybe a fake heart..

He is a creature of this world in every sense of the word.And he will die with his sick pathetic kind.

This separation of essences is what gives me hope.

[question everything]

4. Does this include Medicare?

For most people, their last year of their lives is the most expensive one.

We want to spend whatever we can to add a few more weeks or months to our elders who have lived rich full lives, who probably are in pain and have said their good byes but we are not ready to let go... or hospitals are not.

[On the Road]

5. I Don't Know if It Include Medicare,

but the source of the original chart specifically deals with Medicare. It's worth reading, even though it's a little uncomfortable and I'm not sure I belive it. The basic claim is that Medicare did nothing to reduce elderly mortality, but merely provided financial stability against catastrophic health care costs.

[kikiek]

24. You just said a mouth full! That is so true! It is a toss up as to who is the driving force

behind the aggressive care in the elderly who are ill. One of the problems though is that our society really isn't accepting of death as part of the natural process of living. On the other end you have the corporations like United Health. The CEO from there has now stepped down, and there is a scandal involving back dating stock, but he "earned" 1.6 billion (yes billion) as CEO. They are a for profit health care company that has managed care programs where once people sign up they are paid by Medicare a per Diem to manage the health care of the medicare patient. There are many questions about the access to services under some of these. Since the money now comes out of their profits it can be more difficult to have access to things like PT, OT, Hospice, and needed medical supplies normally provided under the Medicare benefit. Also in some the goal is to reduce the patients meds to certain ones only which on the surface might seem reasonable, but it isn't saving the government at this point just the company managing the care. I do not believe that private for profit corporations should be making money from taxpayer money in health care. The consumer will always be getting the short end of the stick so the stockholder can make a buck. I believe only non profits should exist in health care. They can all still make plenty of money without being obscene.

[mntleo2]

6. DUPE

[mntleo2]

7. The Rich People I Know Are Hypocondriacs

...they are always going to the doctor (whom they call by their first name and invite to their wine tasting parties) and they are always on some kind of medication for losing weight or some imagined ailment.

As a working stiff, I just had to live with the pain or discomfort until it brought me to my knees. THEN MAYBE, I would go if it did not go away, and when I could fit in the time to see somebody. But then my doc is at the community health clinic and to be honest, I get better care from her than my rich acquaintances. Instead of some sterile morgue-like clinic, I go where there is a lot of laughter, the nurses have purple striped hair, and everybody wears those rubber clogs or Earth Shoes. As with most of their patients, they know when I go, there is a damn good REASON, because I would not be there unless I had to be!

In other words from what I can see, the rich go to the doctor for the latest "in" "disease" because they have a lot of time to obsess on every twitch in their bodies. They also have a lot of money to see doctors when they are not sick like for the myriad of allergies they have, liposuction, diets, plastic surgery, and sexual dysfunction.

Uhhh most of the rest of us just live with our misery until it gets better or kills us, which it will do one way or the other anyway whether we are rich or poor, lol.

My 2 cents

Cat In Seattle

[undergroundpanther]

11. I have medicaid

And it is such a PAIN IN THE ASS to find a doctor that accepts it,I don't go to the doc unless I am in some nasty shape myself.

My throat is the exception that opened access to a way to get routine care .When I had a bad throat infection a few years back I found I could not swallow water. I went to the ER I also wasn't getting enough oxygen. Well they found out the reason,I got huge bone spurs on my cervical spine shaped like aztec sacrificial blades. These spurs are sharp they bend my esophagus sideways, so it's up against my windpipe..my whole spine looks like a melting candle with barbs on it.(kinda cool looking in an xray tho)
So if my throat gets infected and swells I am to go to the doc get shots and meds to reduce swelling and kill whatever infection it is pronto even if I think it's minor because when my throat swells up it scrapes my esophagus against the bone spurs every time I swallow, and you'd be surprised how many times you swallow . I go because if my esophagus is scraped too far it could put a hole in it,and if that happens I'd be dead pretty fast.Bleeding to Death.

So I go to my back doc and ENT once a month get barium swallows every 6 months (Yeeech,ICK, barf.).And I take drugs to control the spine symptoms and I must get on any throat infection fast. If I didn't have medicaid I most likely would be dead by now. if not from my throat cutting itself open from the inside,it would be suicide.

But ironic most rich people I've known and I have known a few they were not sick but played it up.They are frightened mice when it comes to discomforts. Because the never have to endure anything and they think they are entitled to not have to suffer , The few rich people I knew could afford preventative care and they don't have the stress levels most poor and working people deal with.(the rich bore I dated and dumped wanted to be a career water skier for chrissake) So they were way healthier than us to begin with.

[undergroundpanther]

8. Rich people are pampered pigs

They get tended to every pain every minor problem.
infantile tapeworms they are.

While poor and working class people like my roommate can't get a tooth filling that fell out about two months ago re filled because no dentists are open on Saturdays on his *cough* "insurance"plan.
If he was rich he would not be having such a hard time getting a goddamn filling replaced.They are not screwed by debt from paying off their mom's health care bills on credit, the only way he could pay it His mom has Alzheimer's and health problems.And the fucking insurance she had had a requirement for "pre approval" and when his mom was going into diabetic shock that was not the time to haggle with bean counters. So they screwed him on a technicality and he works like a dog to pay that shit off..Rich people NEVER have to deal with that.


Because the rich are not like you and I . They got money to burn.
They can afford to take time off during the week (if they work at all) for not only trips to the dentist ,they can get a ceramic filling,a gold one,some tooth whitening and afford to stop over at the gym workout and get a massage, go to their therapist, attend a yoga class and go to a homeopathic hoohaa guy,and they can afford to eat healthy food, and buy a few videos to watch with their decadent buddies with the best TV available and decadent munchies prepared by the"help".. Oh what a busy monday.

I hate rich shit heads who have no clue. I wish I could take their wealth away,and give it to all the people that are struggling. If I made the rich poor by magic or something I bet slumming it will never be the same for these pigs .Because they'd be LIVING it, trapped in it like the millions they exploit.And maybe when they suffer like the majority does, I can say,will be happy watching them have temper tantrums dealing with the SHIT they put poor and working people through everyday.I will laugh at these rich people's whining at encountering real pain for once. Trust me.

I wish every ceo was forced to be gutter punk poor for the rest of their lives..

When the stock market crashed rich assholes leaped to their deaths they feared being poor so much. Maybe we will get to some see the top 1 or 2 % rich pigs kill themselves someday.I hope so.

[fed-up]

10. 30% of health care dollars go to "administrative costs" (insurance companies)-single payer-universal

health care is the most sensible solution

http://www.onecarenow.org

[RB TexLa]

12. And yet when I mention my doing my part to hold down health care spending

on here I am bashed for it. Amazing.

[w4rma]

23. huh? What's your part? (nt)

[RB TexLa]

28. Not giving my money or the insurance company's money to medical providers

[w4rma]

29. I don't understand. Doctors need to get paid for the work they do.

Doctors spend (and keep on spending) a huge portion of their lives (and money) to learn and stay on top of their trade.

And the insurance company doesn't really provide a service except to insert themselves as a middle man in between you and the doctor. The system can work without the insurance companies and their 30% cut.

[RB TexLa]

30. And if you don't have doctors do work, then you don't have to give them your money

[endarkenment]

41. You do realize you are not making much sense, right?

If you have a serious medical condition you have to get medical help or you will likely die.

[Alcibiades]

42. It's that line of thinking that they want you to believe

Firstly, that's a pretty big "if." Most people don't have a serious medical condition. Secondly, even if you do, there's no guarantee that the doctors will not kill you themselves (I've seen it happen twice when I was a medical aide), or that the hospital environment will not kill you (putting all the sick people in one location seems pretty obviously a recipe for disaster, I don't care how often the staff wash their hands). An estimated 100,000 people a year die from "complications" involved in their medical treatment. Furthermore, an unknown proportion of ailments will heal without treatment.

That being said, if you find a lump or a change in a mole or something, or anything you suspect might be serious, get medical treatment right away. My wife delivered our son at one of the best medical centers in the country, and I am certain that she would have died at an inferior institution. And it's high time we got single payer national health care. On the other hand, it's pretty clear lots of people (who do have coverage) overuse our health care system, and I think there's an incentive for them to do so. It's a backwards country we live in wherein 93 year-olds can get just about anything at government expense, but young working people are denied care because they cannot afford it.

[endarkenment]

46. What line of thinking?

Are you really suggesting that people with a serious medical condition not seek qualified professional medical care? Do we have different meanings for the word 'serious'?

[Alcibiades]

47. Quite possibly

Here I take it to mean "life threatening" or "potentially fatal."

Serious might also, however, mean "chronic." You could spend mega bucks on a chronic, treatable but incurable, condition for which there are treatments other than being under a doctor's care.

Anyway, if you read what I wrote, you know that I wasn't suggesting people who need treatment forgo treatment. The bigger problem, by far, is people who should have access being denied access.

That does not mean, however, that there are not some people with insurance who take up hypochondria as a kind of hobby. My own mother is one. Not every bout of the cold or flu requires a visit to a specialist--that's all I was suggesting. I think people should judge for themselves when medical treatment is needed, and not just go in for treatment without regard for whether it is needed. Some of our problems are caused by this very thing--for example, drug-resistant strains of various pathogens have developed as a consequence of the over-prescription of antibiotics, often for conditions not curable by antibiotics.

[RB TexLa]

48. I don't have any medical conditions. However it is much more than "likely" I will die.

[greenman3610]

13. are these "rich people", or just

people, maybe older, on whom we practice the
majority of highly interventional techie medicine -
costs being extraordinarily high for joint replacements,
heart surgery, etc - much of which could
be avoided if we showed people other paths to health.

if so, what do we do.
people want what they want, and
what they want is - drugs and surgery.
They DEMAND it.

[TexasLady]

14. I know of NO affordable insurance for our income bracket

I have had to get my two daughters on medicaid so I could get the oldest one new hearing aids before college, and so I could get the other younger one ANY help.

It's true. I tried a sixty mile radius for any doctors who would take medicaid...The oldest is being helped because her bio dad has her on good insurance..tho it wont pay for her damn hearing aids.We are praying that we can get those hearing aids for her...
the younger daughter is in a world of hurt, because even though she has medicaid, it does her no good. Im on my fourth day of calling, and will have to probably venture out to 100 miles from home. Not looking too good either.

Texas has NO cheap insurance for adults, until you are much older, as in medicare. So, I pay for my doc and dentist visits cash only. If there's any money left after bills. I also spent nearly three grand on dental work, and it took me just about three years to do THAT.

I got off the phone crying after the last call today. Lady said that the medicaid isnt getting paid, therefore no docs or clinics want to take it.

[AdHocSolver]

15. People should shop for health care like they buy a car - if you think you have a heart problem...

visit several hospitals in your area and ask for their price lists. Negotiate a better price. Tell them that your brother-in-law may need cataract surgery and you will steer him their way if they give you a good deal.

Hospitals are first and foremost corporate businesses and are run as such. Even the so-called nonprofits are run to make a profit. The doctors are mere employees and their salaries and promotions depend on how much business they bring in.

The closest business to serve as a model is the automobile dealership. When you buy a car, the salesman are always trying to push you into a more expensive model with more options. The service department has a long list of maintenance items that they push that are unnecessary or overpriced for what you get.

Similarly, each hospital in a given area wants its own CAT scan unit, or MRI unit, even though there aren't enough legitimate cases to keep such units busy in one hospital, let alone three or four hospitals. So every case of hangnail requires a CAT scan just to be safe (and to pay for the thing).

The joke about health care accounts and tax breaks for such accounts is that if you don't have the money to put into it, then you're not paying much in taxes anyway. Only people who are rich enough to pay for health care will benefit. As for consumers shopping for lower health care costs, I would hope that my sarcastic first paragraph puts that idiocy to rest.

One last important point to make. Hospitals and insurance companies and drug companies are not independent entities. Investment companies hold stocks in drug companies and health insurance companies and hospitals and medical clinics. All of these entities are tied together financially and work together to increase each other's profits.

[undergroundpanther]

20. If you have a heart problem

You probably will not be covered for it with insurance. They get out of helping people with that under the pre existing condition excuse.

[hunter]

21. I dunno, grasshopper...

When my wife was bleeding to death, I really wasn't in any kind of mood to negotiate.

But I've got pretty good at negotiating after the box of bills is delivered.

Call from mean lady in collections: "You owe us a lot of money! Send it to us! Now!"

Me: "I could send you a check for 1/100 of that, but I'm afraid it would bounce..."

Collections: "How much can you send us????"

"Um, $35."

It can go on for years and years that way... They always try to make you sign a "payment plan" of some sort too, but I've learned that if I do, it's almost like asking for more shit to fall out of the sky.

I think if I'm ever free of the medical bills that drag me down it will be because I'm dead.

;)

[kikiek]

26. Don't forget the for profit nursing homes and assisted livings. People need to

be aware of what kind of care facility their loved ones are going into. Some look pretty on the surface, but the kind of care they receive may not be what they think. Often times they are cutting costs and the staff will be minimal and not trained. There are many where they staff are care attendants, and haven't the training of a nurses aide even. They are the primary ones caring for our societies most vulnerable citizens, and even passing the medication. I am a union nurse, and a recent meeting told us what we are up against at our non profit facility. Despite the numerous studies that show patient outcomes are directly affected by fewer trained nurses, they are trying to cut costs by increasing the patient to nurse ratio. Dangerous and disgusting.

[knitter4democracy]

37. So, you're going to tell the EMTs to wait for you to call around?

That's the problem with the market model in medicine--it's not like you can make a truly informed decision. One hospital might be cheaper but have doctors covering the unit who have had their licenses suspended or been put on probation because they're so dang negligent that people die (Not like I would know which one that would be . . . :eyes:). The other hospital might be more expensive and also have the cardiologist who came up with the medicine-coated stents or a doctor who is president of his state association and has won many awards.

Oh, and on the entities all being tied together? Yeah, it's not really like that. Most of the time, they're quite antagonistic. The insurance companies keep trying to stop payments to the hospitals or put them off for two years and then argue every single charge (BC/BS and Aetna are notorious for this). Hospitals want to keep all the doctors in the area that they can so they get as much billing as possible, but the doctors are all competing against each other for the same pool of patients, and that competition can sometimes get quite nasty.

[Alcibiades]

43. "If you think you have a heart problem"

Sometimes, the first warning of a heart problem is a serious heart attack. I'm not going to haggle while they open up my chest.

If we want to lower costs, we should get a single-payer system wherein the government has actual power to negotiate prices.

[Shallah Kali]

50. Great idea for the healthy with the luxary of time and stamina to shop around. The ill simply can't

and even their family gets worn out. It is hard enough trying to find a decent doctor who has a clue, doesn't want to pump you full of medications & ship you off to specialists for every little thing, much less an affordable one is trying enough IMO. I don't know if you were joking or not so excuse my serious reply if you were simply being scarcastic.

[eridani]

16. Basic fact: you are probably not going to get expensively sick.

--just as you are very unlikely to have a house fire. 15% of the population (in EVERY age and income demographic) accounts for 85% of the expenses. Clean living efforts on the part of the majority of mostly healthy people have ZERO effect on overal costs, though they can dramatically improve average quality of life. We don't impose the entire expense of fire departments only on those who have fires, so WHYTHEHELL should we shove off paying for health care onto the seriously sick? Both health care and fire protection ought to be treated as PUBLIC GOODS!

[Cobalt Violet]

33. I wish that were true for me.

But it's too late.

[eridani]

53. Sorry for your pain

Somebody is going to be in that unlucky 15%, and we as a society ought to regard ponying up the expense as a public good.

[ComerPerro]

44. Thats a nice analogy actually

[roody]

17. This is one problem that Cubans don't have.

[ComerPerro]

45. I still think I'd prefer no health insurance here to living in Cuba

[roody]

54. Have you been there? It is a wonderful place.

[ComerPerro]

55. somehow I doubt it. I am sure the quaint and novel aspects wear off pretty fast

[yurbud]

18. so if those people would just NOT go to the doctor and politely drop dead, problem solved

[Lasher]

19. Implants for trophy wives, ya think?

When I was 20 I didn't have two nickels to rub together. Now I'm 58 and I have more money (but I'm not in the top 30% that's for sure). I'm also likely to need more medical care than I did when I was 20. Like the colonoscopy that I got this year.

Maybe this has something to do with it. Young folks have less money and need less medical care.

But there's plenty of old folks who don't get medical care simply because they can't afford it. Single payer universal healthcare is the answer.

[POAS]

22. Don't forget the hair transplants!

Universal healthcare is the answer. I don't know who first pointed it out but we are already paying for it, we just aren't getting it.

[POAS]

25. Maybe I'm reading this study wrong BUT

here is my take.

This isn't about the top 1% of wealth holders using 30% of the health care resources but rather that only 1% of all people spending on healthcare actually spent 30% of all moneys spent on health care.

Without digging deeper it would be hard to attribute that spending to a specific income group. It seems more likely to me that it is the sickest among us that consume the vast majority of medical resources. It stands to reason that since the vast majority do not suffer from major health problems that they would use fewer resources and spend fewer dollars (their own or an insurers) on health care.

Regardless of the above, the solution has to be spreading the risk across the largest population group. That means making universal healthcare a must becuase it escludes noone and spreads the cost most efficiently.

[kikiek]

27. I think you are right about both.

[Cobalt Violet]

32. That's my take on it too. n/t

[knitter4democracy]

38. That's how I read it, too.

It's similar to other studies I've seen. It's not so much the rich as it is the really sick.

[On the Road]

40. You are Correct

I must have misread it originally. That's what happens posting after midnight.

The numbers make a lot more sense thinking about the 1% who have extraordinarily high medical costs. Many people never see a doctor in any given year, but someone on intensive care can spend hundreds of thousands of dollars in no time.

I expect a lot of these people in the top percentiles are people in hospitals under long-term intensive treatment.

[KT2000]

49. Thank you for saying this

I read all the linked articles about the study to try to understand the figures but concluded what you said.
Thre funny thing is that this economist is trying to make the case against univeral health insurance with these figures but it shows the opposite.
The top 1% are the really sick, chronically sick and terminally sick. I know insurance companies want to get rid of those people and insure only the ones who use the system the least.
One guarantee of that is to keep health insurance employment based.
If a person is too sick to work - they lose their insurance. Happens all the time.

[Roland99]

31. All of the direct-to-consumer advertising for drugs and surgeries

and the battery of tests (probably often not necessary) given to fight off any shred of liability.

[Shallah Kali]

51. don't forget many times every specalist you are shipped off to wants to retest you even if you just

got the results. This has happened to my grandparents and others I know. medical care should be not-for profit. doctors shouldn't be able to invest in medical labs which encourages this behavior.

[Jcrowley]

34. K&R n/t

[NewJeffCT]

35. This is not a rich/poor issue - the expensive costs

are related to things like long-term care for cancer patients undergoing extensive chemotherapy... long term rehab, etc The cost will be the generally same whether it is Donald Trump undergoing the treatment or somebody that works as a janitor in one of Trump's casinos in Atlantic City. The difference is that Trump will have top insurance to pay the millions in cost, while the janitor would likely be at least partially at the state's expense. (Trump will likely go to a better hospital, but chemo isn't cheap no matter where you go...)

I have a friend in his late 30s who has been out of work for 2 1/2 years now because he had a degenerative condition that led to him having both his hips replaced. He undergoes P/T just about every day still, and was in a nursing home for about a year after the first hip replacement. He had a decent job (I'm guessing around $50K/year, which is okay in Connecticut) and has been on disability for the entire time. But, his insurance (and, I think now Social Security because he probably won't be able to work again) has paid a ton of money for all of this.

[shield20]

36. Go to the original article makes more sense...more $$ avail = higher costs

http://economistsview.typepad.com/economistsview/2007/02/amy_finkelstein.html

It IS NOT about wealth - it IS about medicare.
Basically, health insurance allows people to spend more, so doctors/hospitals WILL CHARGE MORE. Justifiably attimes because they can provide more too!
AND "One factor is that when individuals have insurance, they tend to consume more health care."

"For evidence of how such programs can lead to increased spending, just look at the effects of the introduction of Medicare in 1966. Medicare provides health-insurance coverage to virtually all Americans aged 65 and over. Prior to its enactment, only about one-quarter of these individuals had any meaningful health insurance. As a result of Medicare's introduction, about three-quarters of the elderly ... gained health-insurance coverage...sector. By 1970, the program caused a 37% increase in hospital spending. This is an enormous number. If I extrapolate from the Medicare "

"Here are some statistics related to the paper Robin has used in presentations. This table shows that medical spending is very skewed: If you order people according to their spending on health care, the top 10% of spenders account for 72% of all spending and the top 1% of spenders account for 30% of all spending.

Share of health care spenders Cumulative share of US medical spending
Top 1% 30%
Top 5% 58%
Top 10% 72%
Top 30% 90%
Total population 100%
Source: Berk & Monheit (1992)"

[hedgehog]

39. It has nothing to do with rich or poor; what the numbers says is

that of those people who account for medical costs (presumably omitting people who don't have the money for a doctor), the sickest ones account for most of the money. Consider this; one guy is being treated for diabetes, emphysema and heart disease while 9 others just come in for an annual check-up. The first guy is going to see a doctor a dozen times a year at least and have all kinds of prescriptions. It only makes sense; why would healthy people spend money on health care?

Two more points:

1st: clean living is no guarantee of health. Diseases such depression, rheumatoid arthritis, lupus, fibermaylagia can hit people out of the blue regardless of following all the rules about diet, exercise, not smoking etc, etc. As the article notes, people need insurance to avoid financial catastrophe. Medical bills are a major (the leading?) cause of personal bankruptcy in this country. Factor them out and we have one of th lowest rates of personal bankruptcy in the world.

2nd Point: I have no idea what Medicare and Medicaid have done for mortality rates, but I do know they've decreased morbidity rat4es. I can remember back in the 60's when people finally got cataract surgery because they couldn't afford it before Medicare. Surprise, surprise, what was major surgery back than is now a fairly routine out patient procedure. You don't suppose the increased frequency of this operation led to better and cheaper procedures, do you? People may not be living longer, but they are living better. My grandfather could barely walk because of arthritis in his hips. Today he'd have them replaced and would be out working in his garden instead of confined to an easy chair.

[TheBaldyMan]

52. This isn't strange, the sicker you are the more resources you need

just thank god you're not ill enough to be in the top 1%