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THE ECONOMICS OF COMPETITION IN HEALTH INSURANCE- THE IRISH CASE STUDY. Trinity Economic Paper Series. Paper No. 2000/9. JEL Classification: L82
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1 THE ECONOMICS OF COMPETITION IN HEALTH INSURANCE- THE IRISH CASE STUDY. Trinity Economic Paper Series Paper No. 2000/9 JEL Classification: L82 Sean D. Barrett, Ph.D, FTCD, Department of Economics, Trinity College, Dublin. Acknowledgements The views expressed in this paper belong to the author and do not necessarily reflect the views of the Department of Economics, TCD.
2 I INTRODUCTION. In the White Paper on Private Health Insurance (WP) in 1999 the Government of Ireland decided against competition among the providers of private health insurance. This paper reviews the economic aspects of the decision to forego in health insurance the normal benefits of competition such as the stimulus of new market entrants, competitive pressures to reduce costs and the needs to respond to consumer preferences and to innovate. II THE CASE AGAINST COMPETITION The introduction to the White Paper notes that in submissions "widespread support was expressed for the core principles of community rating, open enrolment, and lifetime cover." (WP,2). Lifetime Community Rating requires the same premium regardless of age, gender, sexual orientation or current or prospective health status. This requirement is enforced under the Health Insurance Act, The White Paper states that "community rating is the cornerstone of the Irish health insurance system. In the absence of community rating, today's healthy individual could become tomorrow's uninsurable risk... In particular, the intergenerational solidarity which is at the very core of community rating in Ireland has made insurance accessible to those( i.e. the elderly and chronically ill) who might not be able to afford the cost of cover." (p.33). The reference to the elderly and chronically ill must be qualified however. O''Shea (1999) notes that private long-term care insurance is currently not available in Ireland." (p.5) Community rating depends, however, on younger members joining the health insurance schemes in order to provide the resources from which cross-subsidisation may take place. The White Paper proposes a maximum premium loading for those who join a scheme in middle age or later. The loading ranges from 10% for those joining at ages 35 to 44 to 80% for those who join at age 65 or over. In addition the White Paper allows insurers " the discretion to charge a premium loading to people who switch to plans with a higher level of cover at a later stage in life" ( WP,35). Community rating is further eroded in the White Paper by the provision to increase from 21 to 23 years the upper age for reduced premiums for students. On the other hand the White Paper rejected a proposal to charge lower premiums to non-smokers. "It was considered that this could have undermined the community rating system. In addition, issues relating to effectively implementing such a measure and technical difficulties in relation to risk 1
3 equalisation were identified." (WP, 36) The White Paper states that " any loading for smokers would be unlikely to impact on the behaviour of insured persons or the cost of claims which may be attributable to smoking induced illnesses. In addition, the Government are concerned that to penalise any specific lifestyle factor could lead to demands for other risk factors to be taken into account thereby undermining community rating." Open enrolment is currently subject to moratoria on payment of benefits for specified periods following first enrolment as well as in respect of claims arising from a condition that existed prior to enroling. The general moratorium or waiting period is currently 26 weeks. In the case of maternity and a person over 55 at the age of enrolment the initial waiting period is 52 weeks. The White Paper recommends extending the initial waiting period to 104 weeks for persons aged 65 or over. The permitted waiting period is not more than 5, 7 or 10 years on payment of benefit for treatment arising from a pre-existing condition where the age of enrolment was respectively under 55, between 55 and 60 and between 60 and 65. The White Paper extended the entitlement to cover under open enrolment provisions to persons aged 65 and over with a maximum waiting time period of 2 years and a waiting period in respect of pre-existing conditions at the existing maximum of ten years. Lifetime cover provides that as insured persons gets older, their health deteriorates or they sustain a serious injury their health insurance cover may not be terminated by the insurer. In addition there is a prescribed minimum benefit of 100 days in-patient treatment in a private psychiatric hospital during a calendar year. The White Paper notes that one insurer provides for cover up to 180 days. The remaining part of the policy environment for commercial insurance in the White Paper is loss compensation or risk equalisation. The White Paper defines risk equalisation as "a process which aims to equitably neutralise differences in health insurance costs that arise due to variations in risk profiles. This results in cash transfers from insurers with healthier than average risk profiles to those with less favourable risk profiles." (WP, 41). Given the other parameters within which the health insurance market is required to operate why is the additional constraint or safeguard required? The White Paper states that " without risk equalisation, each health insurer would have a strong incentive to target low-risk individuals (preferred risk selection) so as to be able to charge a lower community rate (or take a higher profit margin) than its competitors. Even with compulsory open enrolment, health insurers could seek to achieve a better risk profile by, for example, selective marketing techniques, targeting group occupational schemes, benefit design, or selective quality of service" (WP, 41). 2
4 The case made in the White Paper is that " any process, whether deliberate or accidental, which gives rise to significant differences in risk profiles" would cause per capita claims costs to spiral for insurers left with a higher proportion of less healthy individuals. "This, in a community rated environment would lead to significant market instability and erosion of public confidence." (WP, 41). Competition in the health insurance market would be restricted to "distribution, brand customer responsiveness, product innovation, claims management, purchasing efficiency and administrative efficiency." (WP, 42). The Government's risk equalisation proposals are due to come into force in June They will be implemented by equalising casemix index scores within each age and gender category. Casemix is a measure of the relative resource intensity of a group of claims. The number of claims in each category is multiplied by a weighting factor which indicates its relative cost. The White Paper's prescribed minimum equalised benefits are based on VHI schedules because they represented established market practices at that time." III THE DEVELOPMENT OF PRIVATE HEALTH INSURANCE IN IRELAND. The Voluntary Health Insurance Board was established in Its purpose was to provide insurance for health services for the richest 15 per cent of the population who were not entitled to free public hospital services. In 1979 the top income group became eligible for free hospital accommodation and in 1991 this was extended to hospital consultant services. Membership of VHI has increased from 288,496 in 1968, ten years after its foundation, to 697,346 in 1979, 1,289,262 in 1991 and 1,464,757 in In the year ended February 1999 VHI had subscription income of 343m and accumulated reserves of 87m. (WP, 80). The extension of full eligibility for the public health services to the richest 15% of the population in 1991 was a regressive measure. The Household Budget Survey indicates that the richest third of households spend ten times as much on health insurance as the lowest income third. Only at the seventh decile does private health insurance expenditure exceed the average over all households. The benefits sought by the state from community rating in the Irish health insurance market are therefore heavily skewed up in the income distribution scale. The market being regulated is a discretionary one in a system where all persons, no matter how high their incomes, have full eligibility for hospital and consultants' fees. The private health insurance market was opened to competition by the Health Insurance Act, In 1999 there were million members of private health insurance schemes, of which 1.465m were in VHI, giving it a 93.6% market share. There were three 3
5 group schemes for the Gardai, Prison Officers and ESB staff. The only competitor in the general health insurance market was BUPA with an estimated 2% market share. The cost of VHI premiums rose by 91% between 1990 and 1999 (WP, 81). The increase in gross current expenditure on the public health service from 1.4b in 1990 to 4.3b in 1999 was 207%. The increase in the consumer price index over the same period was 24%. Ireland thus has serious problems of cost escalation in the public health service. The increase in gross current public health expenditure in the 1990s was 2.3 times the increase in VHI premiums which in turn rose by 3.8 times the consumer price index. The basket of goods and services covered by VHI differs from those provided by the exchequer funded health services. The increase in VHI premiums is transparent in members' bills whereas the more rapid escalation in the cost of the public health service is obscured in the public mind by the huge revenue buoyancy in the public finances in the second half of the 1990s. The administration cost of VHI is 6.7 per cent of premium revenues (WP, 81). The potential gains from competition in respect of administration cost savings is therefore small. Despite operating in a health sector with rapidly escalating public health service costs VHI has managed to restrict the growth of its premiums to 44% of the rate of increase in public health service costs. On the other hand the VHI premium increase was 3.8 times the increase in consumer prices indicating scope for a better price performance by a new entrant. VHI is controlled by the Department of Health which also regulates the market in health insurance and controls prices in the public sector. The White Paper proposes to remove VHI from the province of the Department of Health and to have a Health Insurance Authority to regulate the sector. IV GOVERNMENT INTERVENTION IN THE MARKET FOR HEALTH SERVICES. Government intervention in the market for health services in Ireland is a large and rapidly increasing part of the national budget. Implicit in that policy is that, left to themselves, people would spend too little on their health. The White Paper estimates that approximately 75 per cent of health services expenditures are publicly funded. "The remaining 25 per cent comprises expenditure by private health insurance undertakings and private spending by households" (WP, 11). The composition of the latter is 17 per cent spent by households and 8 per cent spent by private insurance companies. (O'Rourke, p.1) 4
6 The reasons why, in the absence of government intervention, individuals might spend too little on their health services include factors such as; (a) ignorance of the costs and risks involved (b) the existence of spillover benefits or externalities to society as a whole from the doctorpatient transaction; and (c) the inability of low income persons to afford health expenditures (Buchanan, 1966). The contrary arguments are that the problem of ignorance is best dealt with by the supply of information rather than by public provision. It is also maintained that the spillover benefits from health expenditures are in fact small and that the benefits overwhelmingly accrue to patients rather than to society as a whole. The inability of low income persons to afford healthcare could also be tackled by programmes of income distribution designed to benefit low income as a whole (Allan,C, 1971, 114). In 1973 the International Economics Association examined a number of causes of the rapidly rising cost of healthcare such as: (a) the increase in medical expenditures rather than changes in diet, exercise and other aspects of lifestyle; (b) the moral hazard factor caused by both social and commercial insurance finance of health services; (c) the ability of producers of medical services to determine both the demand for, and supply of, healthcare services; and (d) the poor measures of outcomes of health expenditures (Perlman,1974). Tussing (1985) found several of the above factors significant in his examination of Irish healthcare expenditures. There was a heavy emphasis on hospital rather than primary healthcare expenditure. Tussing recommended free general practitioner services for all and charges for outpatient and inpatient services to reflect social priorities in favour of primary healthcare. He favoured group general practice as a way to reduce referral rates to hospital by general practitioners. Tussing proposed medical audit to examine differences in healthcare costs for similar conditions and outcomes. Tussing also recommended capitation rather than fee per item systems of payment and the establishment of pre-paid group plans (PPGPs) or health maintenance organisations (HMOs) as an alternative to both commercial and social insurance in order to give doctors an equity stake in low cost treatments. The Commission on Health Funding found that " the major attraction of the HMO is that the individual making the resource-using decision is either an owner or an employee of 5
7 the organisation which bears the resultant cost. Consequently, preventive care is emphasised; medicines, X rays and tests are not ordered unnecessarily; and, although studies show that patients in those plans have as many, or more, visits to the doctor as under traditional models, they typically have less hospitalisation. This has been found to be the principal reason for the savings which are estimated at per cent on traditional models" (CHF,101). There has been a large increase in employment in the Irish health service in recent decades. The White Paper estimates that there are currently over 75,000 employees in the service. This compares with 43,000 in 1975, 58,400 in 1990, and 65,800 in Nurses in 1996 were the largest single category of employees in the health service, accounting for 41 per cent of all staff. The Irish ratio of nurses to hospital beds for example, in 1987 was 1.2. This compared with 0.5 in Belgium, 0.45 in Germany, 0.55 in France, 0.47 in Spain, 0.91 in New Zealand and 0.69 in Britain. (OECD,1990, Table 46). The number of nurses in Ireland increased by a further 9 per cent between 1987 and 1996 while the number of beds remained constant. OECD studies indicate that the Irish healthcare system is heavily based on hospitalisation. The estimate for 1983 is that Ireland spent 73.4% of its public health care expenditure on institutional services compared to an OECD average of 54.4% and 59.7 per cent in the United Kingdom (OECD, 1990, 33). In 1982 the hospitalisation rate in Ireland was 17.6 per cent compared to 12.7 per cent in the United Kingdom (OECD, 1985, 15). Britain's share of its population over 65 years is 40 per cent higher than the share in Ireland. Since 15.5 per cent of the population of Britain is over 65 years compared to 11.0 per cent in Ireland (OECD, 1990, 88) one would expect hospitalisation rates in Ireland to be significantly lower than in Britain rather than 38 per cent higher as in The cost of health services by age is illustrated as a U-shaped curve with higher health expenditures by the young and the old than by the 16 to 44 age group. For example United Kingdom data for the three years to 1998/1999 indicate that expenditure on the hospital and community health services was lowest in the 5 to 15 age group. Expenditures per head on the over 85, 75 to 85 and 65 to 75 age groups were, respectively, 7.4, 4.7, and 1.4 times the expenditures on the age group 16 to 44. The problem of a relatively young population and a relatively high cost health service is shared by Ireland and the United States whereas Sweden, Norway, Denmark, Germany and the United Kingdom have a relatively large number of older people in their populations (Jonsson, OECD, 1990). O'Hagan (1984) found that the cost per hospital bednight increased from to times GDP per head in Ireland between 1966 and The cost ratio increase of 6
8 104.6 per cent compared with per cent in Germany, 81.1per cent in Britain,71.8 per cent in Sweden, 65.8 per cent in the United States and reductions in the cost ratio in Australia, Austria, and Finland. Inpatient price indices for the years 1960 to 1983 show the Irish increase, at 20.3 times compared to 10.9 in the United Kingdom and 9.3 for sixteen countries. Only Italy at 21.7 exceeded the Irish inpatient price index growth. (OECD, 1990). In addition to meeting 75 per cent of the total health bill the government in Ireland provides assistance to private health expenditures. The White Paper lists the most prominent incentives by the State to private health insurance as tax relief on health insurance contributions, public hospital charges to private patients at below the economic cost and the bearing of costs by the state in relation to accident and emergency services, national and tertiary specialities and professional training (WP, 75). The White Paper estimated the cost of private health insurance tax relief in 1999 at 62m. (WP, 24). The private hospital sector provides 2,500 private and semi-private beds compared to 2,500, also designated as private beds in public hospitals, some 21 per cent of the total beds in public hospitals. The White Paper estimated that there was a subsidy of 35m to private patients in public hospitals because " the charges are not explicitly related to the real costs of maintaining and providing services to private patients and are intended only as a contribution to the cost of care in public hospitals." (WP. 25). The White Paper states that " the Government will therefore make arrangements for the phased introduction of economic pricing over a period of 5 to 7 years." (WP, 26). Of the 12,292 beds in public acute hospitals 21 per cent are designated private beds and 6 per cent are non-designated. No charge is made for these " non-designated" beds to private patients according to the White Paper " even though they would be in receipt of intensive and costly care at the time. This is a particularly advantageous situation for insurers, as public hospitals carry the costs of the services provided to insured persons." (WP. 26). Of 1,208 medical consultants, only 250 or 21 per cent are entirely in private practice. The White Paper states that the fee per item system of paying consultants in public hospitals in respect of their private patients compared to salary in respect of public patients suggests that " a stronger incentive exists for those consultants who are significantly involved in private practice to devote a disproportionate amount of personal time on these private patients. This situation is exacerbated by the fact that the private hospitals employ relatively few consultant or other medical staff of their own, relying to a great degree on the availability of doctors who also hold public contracts." (WP, 13). The contrary point is, of course, that 7
9 all taxpayers have contributed to the public health service and have thus a call on it when private hospitals find it too expensive to provide certain services. The White Paper indicates, therefore, that the stand-alone private sector in the Irish health services is relatively small and that there is a complex relationship between public and private sector costs in public sector hospitals. V GOVERNMENT INTERVENTION IN THE HEALTH INSURANCE MARKET. The White Paper gives the reasons for government intervention to increase consumer expenditure on private health insurance as follows:- (a) individuals taking responsibility for meeting the cost of their own healthcare displaces demand that would otherwise fall on the public health system. (b) private health insurance provides facilities to meet a burgeoning demand for acute care. (c) private health insurance is affordable and accessible because of community rating and open enrolment (WP, 23) Research by VHI and the ESRI indicates that consumers buy private health insurance for the following reasons;- (a) protection against large hospital/medical bills (b) peace of mind about healthcare needs (c) faster access to hospital beds/avoidance of waiting lists (d) option of private/semi-private accommodation. (WP, 23). While the White Paper presents community rating, open enrolment and lifetime cover as the values underpinning the health insurance market O'Connor (1999) presents a less benign view. "The VHI, as a monopoly, was free to choose how to levy its members to cover its claim cost, and naturally, chose the administratively simple route of open enrolment and lifetime cover. That such features, with minor modifications are now deemed prerequisites of a competitive private medical insurance market speaks volumes for the sheltered evolution of the Irish approach to financing health care!" (p.3). O'Connor also states that, with the option of open enrolment, many potential members may choose to replace promises with personal savings. As they age, they have both saved resources and the same promise as all other members. The benefits from private health insurance are of the hotel type i.e. accommodation and food benefits. As O'Connor emphasises " catastrophic risk is, of course, covered by universal public health access."(p.4). In the health insurance sector " service provision is focused on improvement in choice, access or comfort, rather than the provision of "All Up" healthcare." 8
10 Durkan (1999) contradicts the White Paper statement that " patients availing of private hospital services have always been seen as availing of an alternative service to the public system."(p.12). He says that the sentence is simply wrong. "Patients who opted for private treatment in public hospitals were not availing of an alternative treatment servicethey were availing of the same treatment service, but getting it earlier, and having a variable accommodation service. This was and is a major feature of Private Health Insurance- it provides resources for queue-jumping." (p.4). One policy in Britain offers the patient the option of either private care or a cash payment of 250 per night spent in a public hospital with the choice being made at the time of hospitalisation (Norwich Union, 1999). O'Rourke states that in Ireland "the vast majority of private medical insurance claims are not for major amounts"(p.2) and that private medical insurance funds only 8.1% of healthcare expenditure in Ireland. Government policies to restrict competition in the market for health insurance in Ireland seem therefore to lack an economic rationale. The protected sector provides some benefits which are private goods such as perceived greater comfort and peace of mind and one benefit, the ability to jump the queues, which might be claimed to be a social cost rather than a social benefit. It is also of note that while the protected private health insurance market covers some 42% of the population it contributes only 8.1 per cent of the costs of healthcare in Ireland. The White Paper relies, inter alia, on an OECD assessment of the Irish mixture of public and private healthcare in 1997 to support its policy stance. The OECD acknowledged Ireland's "unique mixture of public and private care" as "having achieved a good provision of healthcare at relatively low cost to the taxpayer." (WP, 14). The OECD noted that a significant private health sector had developed alongside the public sector; that a significant number of people stay in the private system thus relieving the cost of hospital care to the public finances; that working in public hospitals remains attractive to consultants; and that older people remain in the system because health insurance premiums do not vary with age." However the OECD also noted "problems in managing the complicated interface between the public and private provision of medical care." The problems cited include defining the expected commitment of consultants to both sectors; putting charges for the use of public hospitals on a more economic basis and the need to avoid high risk groups being pushed into the public sector. (WP, 14). Three years later the OECD report appears complacent about the provision of healthcare at a relatively low cost to the taxpayer. Public health spending has increased by 52 per cent, comprising almost 30 per cent in 1998 and 1999 (WP, 27) and 17 per cent in
11 thus weakening the OECD argument. An earlier study by Schieber and Poullier found that over the period the elasticity of per capita health care expenditure relative to GDP was 1.5 in Ireland, 1.3 in the OECD as a whole and 1.1 in the United Kingdom. While a significant number of people have private health insurance their contribution to the health service costs is less than a fifth of their share in the population. The benefits to society as a whole from the policy are not obvious in the case of private benefits such as comfort and peace of mind and open to question in the case of incentives to jump health service queues. VI COMPETITION IN HEALTH INSURANCE AND HEALTH SERVICE EFFICIENCY. The interaction between efficiency enhancing proposals such as those by Tussing and deregulation of the health insurance market is an important one. Competition in health insurance might increase total costs if it increased the administration and marketing burden. There might be little impact if the present pattern of healthcare expenditure were financed by two rather than one health insurance company. On the other hand competition in health insurance might stimulate some improvements in resource allocation in the Irish healthcare system. The reduction in hospitalisation rates and hospital unit costs, the substitution of primary care for hospital care, the substitution of capitation payment of doctors for fee per item payments, and incentives to patients to avoid the harm to health caused by factors such as smoking, excess alcohol consumption, and disregard of safety at work, on the roads and in the home, might be some of the results which would flow from the introduction of competition if the insured persons shopped around for better value. The Commission on Health Funding (1989) found that " the introduction of general insurance companies to the private healthcare market in the United Kingdom since 1980, in competition with the longestablished provident associations, has led to innovations such as non-smoker discounts, noclaims bonuses, discounts where the consumer pays a percentage or an initial amount of each claim, and in one case, full cover for the use of approved preferred hospitals but only partial cover for the use of other hospitals." (p.130) The competition proposed by the White Paper is limited to the following areas: 10
12 Distribution, Brand, Customer Responsiveness, Product Innovation, Claims Management, Purchasing Efficient and Administrative Efficiency. (WP, 42). Some of these non-price types of competition would increase costs. Nonprice competition in aviation, for example, led to high costs expensive brand-imaging, service competition in terms of seat pitch and food and drink on offer, decor of aircraft, expensive forms of retailing, and frequency of service with low load factors. Similarly in banking the absence of price competition led to service competition with an increased number of branches. The White Paper rules out the targeting of low-risk individuals and incentives to change the conduct of either the individuals insured or the medical sector. A major complaint by BUPA against the White Paper is that it prevents them from changing the incentive structures for both patients and producers which have pushed up costs. The improvements which BUPA wishes to make which would be negatived by risk equalisation as proposed by the Irish government include the following;- (a) Insurers encouraging people to stay healthy, through screening, preventative programmes and better systems of managed care; (b) Insurers who have shorter lengths of hospital stay; (c) Insurers who encourage day care rather than inpatient care; (d) Insurers who encourage people to use alternative medicines; and (e) Insurers who choose drugs rather than invasive surgery(o'rourke, 1999). The context of risk equalisation in Ireland is one in which everyone is covered for hospital and consultant costs. Government interference in the market for health insurance is thus concerned with bypassing queues and accessing the hotel aspects of hospitals such as perceived differences in food and room furnishings. VHI itself cross subsidises its high cost plans from its basic product. VHI has a 91 per cent market share in Irish health insurance, thus making it impossible for BUPA or possible other new entrants to cross-subsidise such a market dominant company. The benefits of risk equalisation are nil but the cost in deterring new entrants and preventing efficiency improvements are considerable. The White Paper recognises the inefficiencies inherent in the risk equalisation policy it proposes. The White paper states that " the regulations will also be examined and discussions held with insurers with a view to avoiding situations where an application of an "excess" on out-patient services may provide a perverse incentive for minor procedures to be carried out in a hospital setting rather than in a local surgery." (WP, 57) While supporting "steps to promote the position of primary care in the system" the White Paper paradoxically states that " a compulsion to cover primary healthcare is not necessary for the protection of the interests of the common good, as reflected in the core 11
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Big 12 Sports Saturday's Web Extra
The crew from Big 12 Sports Saturday chats about all things sports in this exclusive web and mobile extra.
Tea Party Tim: He gave a very serious and heart felt message. It wasn't the usual political rhetoric that we hear over and over again. Real problems were addressed with real solutions. I am listening to Hillary at this moment and all she is spouting is the same old political bull that has been around for decades. She is an idiot. Trump 2016! Trump 2020!

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MOSCOW, May 1 (Itar-Tass) - Jets of the Russian Ministry for Emergency Situations (EMERCOM) landed in China with a consignment of humanitarian aid to the quake-hit population, the ministry's press service said on Wednesday.
EMERCOM's two Il-76 jets landed at Chengdu Shuangliu International Airport at 06.13 hours GMT and 06.39 hours GMT on Wednesday. They delivered 40 tonnes of humanitarian aid - essentials and food stuffs, the press service said.
On April 28, another 13.5 tonnes of relief were brought to the city of Chengdu by an EMERCOM plane.
The 7.0-magnitude earthquake that rocked Lushan, southwest China's Sichuan Province, on April 20 left nearly 200 dead and 12,000 injured.


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"A lot of schools are really close to offering," said Jackson, who has reportedly received interest from Ball State, Cincinnati, Georgia Tech, Indiana, Iowa, Miami (Ohio), Michigan State, Missouri, Northwestern, Purdue, Stanford and UCLA, among others. "There's some schools that stand out, but it's really close."
One school in the running for Jackson, who also plays running back for Decatur Central, is Northwestern, and Jackson said he has a recruiting visit to Evanston scheduled for April 7.
"I'm pretty high on [Northwestern]," Jackson said. "They have great academics and that's what I really want to do: Go and get a great education wherever I go."
According to Jackson, who burst onto the radar of a number of schools last fall, Northwestern wide receivers coach Dennis Springer has been in contact with him and has been singing the praises of both the Northwestern classrooms and the campus' lakeside scenery.
"We've been talking about how good they are academically," said Jackson, who tallied 17 tackles for loss back in his sophomore campaign in 2010. "[As well as] the campus lifestyle and just where I'd be on their depth chart."
Evanston isn't Jackson's only scheduled stop in the near future, however, as the junior will also be visiting Toledo on Saturday and Northern Illinois on April 8, the day after he visits Northwestern.
Jackson said he wants to play in the Big Ten – and hears from his coaches that he would fit in well in the conference – but he said he is looking first and foremost for a school with a winning tradition and a passion for football.
"They have to win," Jackson said. "They can't lose constantly. And [I'm looking for] a football school – not about another sports program – a football school."
Although Jackson plays on both sides of the ball, most schools have focused on his potential as a linebacker, and the high school standout said he would relish the opportunity to play for a coach with a defensive background such as Pat Fitzgerald.
For now, though – while still in high school – Jackson said he has a number of goals on both sides of the line of scrimmage, as well as some lofty team aspirations.
"We want to be a conference champion," Jackson said. "Hopefully win sectionals – maybe regionals. But I want to rush for at least 750 [yards] and have 100 tackles this year."


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Cardiff City boss Malky Mackay hailed his team's battling performance in Saturday's 0-0 home draw with Everton.
The Welsh club followed up their shock 3-2 victory over Manchester City with a dogged performance against Roberto Martinez's men, earning a deserved point for an impressive defensive display.
And Mackay believes that Cardiff were full value for a point against a side that he believes could have posed a significant threat.
"We played a top team here today, a team that finished sixth in the Premier League last year," he said. "That what I was reinforcing to my players before the game.
"There was no way we could make this after the Lord Mayor's show today and if we had at all come off our game we'd have been beaten and turned over today by a good team.
"Make no mistake we were at it, they were at it and it was two teams matching each other stride for stride. Shots on target I believe it was maybe 3-2 to us but it was very, very tight.
"It was a game of few chances but we were playing against very good players here today."
The Scot went on to praise his players' focus following a week in which they were widely lauded for an outstanding performance against Manchester City.
"I knew the team coming today were a very good team and I think people were still wanting to talk to us about Manchester City when we've actually got a game against a top team," he added.
"The other thing was that we kept a clean sheet today, which was absolutely deserved I felt.
"I looked at my back four and my goalkeeper especially - we defend from the front and our boys worked hard as a unit - but there were two or three exceptional performances in defence."
Mackay also dismissed suggestions that Everton were unfortunate not to be awarded a penalty when Leighton Baines appeared to be felled in the area by Gary Medel in the first half.
"I've not seen it on TV, I only looked at it live," he continued.
"When I looked at it live I felt it would have been incredibly soft had it been given. I felt there was very, very minimal contact and he was on his way down."
|D. Marshall
|A. Taylor
|M. Connolly
|B. Turner
|S. Caulker
|P. Whittingham
|G. Medel
|A. Gunnarsson
|Bo-Kyung Kim
|C. Bellamy
|F. Campbell
|Coach: M. Mackay
|T. Howard
|P. Jagielka
|L. Baines
|S. Distin
|S. Coleman
|S. Pienaar
|L. Osman
|M. Fellaini
|R. Barkley
|K. Mirallas
|N. Jelavić
|Coach: Roberto Martínez
for C. Bellamy 78'
for Bo-Kyung Kim 82'
for G. Medel 89'
for N. Jelavić 68'
for K. Mirallas 86'
|Zidane vows to play Morata more often
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|Bailly sustains knee ligament injury
|Simeone frustrated by Atletico´s finishing
|Conte encouraged crowd as Chelsea deserved it
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|Chelsea ´dominant from first minute to last´ - Cahill
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|´Icon´ Rooney not finished at United - Pereira
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|Lorient dismiss coach Ripoll
|Ronaldo´s impact on football is myth-like - Perez
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|A-League Review: 20,000th goal helps Newcastle Jets to shock comeback
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|Ancelotti admits to bowing to Ronaldo demands
|Ancelotti doubts Conte´s Chelsea can win Premier League
|Romagnoli happy at Milan amid Chelsea links
|City must not change their style - Gundogan
|Conte wants to emulate Mourinho
|Montella: Rising Milan must handle new expectations
|Rummenigge dispels Alaba-Manchester City reports
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|Gundogan hails ´amazing´ duo Guardiola and Klopp
|AC Milan players influenced ref for disallowed goal, fumes Allegri
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|Clean sheet pleases Ancelotti
|Pulis tips Liverpool for title tilt
|Alonso delighted with dominant Bayern display
|Klopp: West Brom draw would have been a joke
|De Boer praises Icardi mentality amid ultras row
|Valdes recovery heartens Karanka
|Spanish football can´t have such a disgraceful referee - Pitarch rages after Barcelona loss
|Luis Enrique fears long absence for Iniesta
|Bilic insists West Ham deserved last-gasp win
|Dortmund were not ready for Bundesliga intensity - Tuchel
|Liverpool 2 West Brom 1: Mane and Coutinho on target for Klopp´s men
|Bayern Munich 2 Borussia Monchengladbach 0: Champions back on track thanks to Costa and Vidal
|Brazil great Ronaldinho considering three contracts
|Luis Enrique, Valencia condemn missile throwing after Barcelona winner
|Wenger to raise a glass after toasting Cech
|Dyche delighted to see Clarets get back to basics
|Moyes claims winner should have been ruled out
|Karanka declares Cech man-of-the-match as Boro make their point
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|Arsenal 0 Middlesbrough 0: Birthday blank for Wenger´s table-toppers
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text:
Lloyd Woodard has been a part of two Bellator tournaments, but seems to have trouble getting past the semifinals. His most recent defeat against Rick Hawn, who Woodard says was his toughest opponent, was due to him not taking the tournament winner serious enough.
Woodard thought his quarterfinal win over Patricky Freire would be the hardest part in the last tournament, but he now knows that he was wrong.
"I thought Patricky was the toughest fight in the tournament," said Woodard to MMA Mania. "I felt I had a pretty big head, probably too big for my body. I had a moment and when I went in there against Rick Hawn, I got frustrated and went after him with my hands down and paid the price."
Woodard was able to submit Freire in the second round at Bellator 62. His loss to Hawn lasted 10 seconds into round two as he was planted with a right hand. That defeat was his second under the Bellator name, with the first being to current lightweight champion Michael Chandler.
Tonight, at Bellator 87, Woodward meets David Rickels in the quarterfinals of the tournament. The main card airs on Spike TV at 10 p.m. ET from the Soaring Eagle Casino in Mount Pleasant, MI.


text:
The average salary of a(n) Human Resources Manager in Amarillo, Texas is $100,188.
The average hourly rate of a(n) Human Resources Manager in Amarillo, Texas is $48.17.
The average bonus of a(n) Human Resources Manager in Amarillo, Texas is $7,935.00.
Kindred At Home
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Education requirements at the discretion of the hiring manager. Demonstrated skills in requirement gathering, resource organization, project/task prioritization...View job on Indeed.com
Texas Tech Univ Health Sciences Ctr
For additional information, please reference the institutional pay plan on the Human Resources webpage. May include assisting in the developing of certain...View job on Indeed.com


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Suggest me home remedies for thick cough
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Dr. Satvinder Bakshi
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Practicing since : 2007
Answered : 2217 Questions
Good evening doctor Greetings I'm facing problems for cough.thick cough.please suggest some home remedy Regards XXXX
Posted Sun, 9 Mar 2014 in Ear, Nose and Throat Problems
Answered by Dr. Satvinder Bakshi 36 minutes later
Brief Answer: please try steam! Detailed Answer: Hello The best and effective way to reduce your cough and clear up the chest will be to start steam inhalation 4 to 5 times a day. You can also take ginger juice with honey., one teaspoon two times a day. You can also take green tea. It is very beneficial! Please avoid cold and spicy food. Also avoid oily food and dairy products. Please meet your doctor if you dont get relief in two or three days. Take care
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Hermitage, MO
Service Providers in or near Hermitage, MO
H&R Docks
138 Long Acres Drive Sunrise Beach, MO 65079 | 573-374-4474
Welcome to H & R Docks, your locally owned and operated Dock Builder serving the…
Wilson & Mee CPAs
1410 E Kearney Street, Suite D Springfield, MO 65803 | (417) 863-1500
Are you tired of cold, impersonal service from storefront accounting offices that don't know your…
(17 reviews)
Architecture & Engineering Consultants
100 Crossings East Drive, Suite 4 Lake Ozark, MO 65049 | (573) 365-2100
Architecture & Engineering Consultants was built on 20+ years of experience in planning, architectural and…
Reece & Nichols Al Elam Real Estate
2860 Bagnell Dam Blvd Lake Ozark, MO 65049 | (573) 365-2311
Gregory Tolbert and Tim Tabor, Reece & Nichols Al Elam Real Estate, are your local…
435 W Kearney Springfield, MO 65803 | 417-831-3447
Audiophile is a Custom High Performance Autosound center and Auto Salon in Springfield, Missouri. 2013…
Integrity Home Care
980 Executive Dr. Osage Beach, MO 65065 | 573-302-7844
Integrity Home Care is an independently and locally owned, full-service, Christian-based Home Health Agency that…
Keys to the Lake Real Estate
2820 Bagnell Dam Blvd. Ste. A-4 Lake Ozark, MO 65049 | (573) 964-5397
Keys to the Lake is a full service Real Estate Company. We sell lakefront homes,…
Golden Rule Insurance Agency
4065 Osage Beach Parkway Osage Beach, MO 65065 | (573) 348-1731
Golden Rule Insurance Agency has been in the insurance business for over 20 years here…
(1 review)
TNT Computers
3797 Osage Beach Parkway, Suite F-1 Osage Beach, MO 65065 | 573-348-2448
For over 13 years, TNT Computers has been your local Computer Repair and Retail Sales store for the…
Accurate Glass LLC
64 N Business Highway 5 Camdenton, MO 65020 | (573) 346-8400
Accurate Glass LLC is a locally owned and operated Auto Glass Shop located near the…
Arnie's Plumbing, Heating and Air Services
421 W Chase Springfield, MO 65803 | (417) 865-8847
We are a full service contractor, doing business in Springfield and the surrounding area for…
(3 reviews)
HMI Fireplace Shops
6656 US Hwy 54 Osage Beach, MO 65065 | (573) 348-9002
"No one warms you like HMI" HMI Fireplace Shops carry a vast array of hearth…
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At OnSite Rehab we offer the hightest degree of patient care. We focus on restoring…
Cool Breeze Marine The Prop Specialists
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Matthes Electric
2886 South Highway 5 Camdenton, Mo 65020 | (573) 216-9776
Welcome to Matthes Electric, your locally owned and operated Electrician for Residential and Commercial electrical…
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text: Tiny Adorable Oil Tanker Makes Pilots Better Trained, Slightly AwkwardDan Nosowitz6/10/09 11:00amFiled to: MiniaturesMiniature oil tankerOil tankersShipsBoatsTrainingOilTankerUkEngland66EditPromoteDismissUndismissHideShare to KinjaToggle Conversation toolsGo to permalink The Warsash Maritime Academy in the UK uses these $245,000 miniature oil tankers to train its pilots—they're incredibly difficult to drive, and simulate all kinds of different emergency situations, all while looking like a coin-operated children's ride. Advertisement The tiny tankers are designed to realistically mimic the driving conditions of their full-sized brothers, with a slightly gentler learning curve. Emergency situations (like a failing engine) can be remotely triggered for training purposes. Oh, and feel free to quote that episode of The Simpsons with the big guy in the tiny car. That's what you guys are here for. [DVICE]Gear from Kinja DealsBestsellers: Rubbermaid FreshWorks Produce Saver ContainersThese Are Your Five Favorite International Travel AdaptersSave $13 On the Bluetooth-Enabled Xbox One S ControllerReply66 repliesLeave a reply


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Author: Robert Harris
Publisher: Hutchinson
10% OFF FOR LITERARY REVIEW READERS (was £20)
About this book:
Behind the locked doors of the Sistine Chapel, one hundred and eighteen cardinals from all over the globe will cast their votes in the world's most secretive election.
They are holy men. But they have ambition. And they have rivals.
Over the next seventy-two hours one of them will become the most powerful spiritual figure on earth.
What Literary Review says:
"Robert Harris's new book is an electric read, like a shot of adrenalin to the heart. Not what one would expect of a plot in which 118 cardinals are locked in a building to pray and vote … an insightful and witty thriller." —Tim Stanley
About the author:
Robert Harris is the author of ten bestselling novels: the Cicero Trilogy - Imperium, Lustrum and Dictator - Fatherland, Enigma, Archangel, Pompeii, The Ghost, The Fear Index, and An Officer and a Spy, which won four prizes including the Walter Scott Prize for Historical Fiction. Several of his books have been filmed, most recently The Ghost, which was directed by Roman Polanski. His work has been translated into thirty-seven languages and he is a Fellow of the Royal Society of Literature.
Giving this book as a present? We can include a personal message from you, handwritten on one of our illustrated Heywood Hill postcards free of charge. Write your message in the 'notes' box at the checkout. If you would like the book gift-wrapped in our famous livery, also free of charge, just let us know.


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The Washington Manual of Patient Safety and Quality Improvement provides a basic framework of many common principles in patient safety and quality improvement to a broad market of medical students and residents, nurses, patient safety officers and pharmacists. Chapters address a practical and multidisciplinary overview of patient safety in complex health caresystems, and each concept is introduced using a clinical vignette. The text introduces models, measurements and tools to assess patient safety and quality improvement, and discusses types of medical errors, how to respond to adverse events, and potential solutions. The book's overall purpose is to highlight specific issues of patient safety relevant to different specialties.
DETTAGLI PRODOTTO torna su
Titolo: Washington Manual of Patient Safety and Quality Improvement
Autori: Fondahn
Editore: Lippincott Williams
Volume: Unico
Edizione: 2016
Lingua: Inglese
Finitura: Copertina flessibile
Pagine: 350


text:
PC Games
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Boxshot & Details
- Developer: Io Interactive
- Publisher: Eidos Interactive
- Genre: Action Adventure
- Release: May 30, 2006
- ESRB: Mature
Question & Answers
Installing hitman on 64bit windows 7
Hi i tried to play hitman blood money on windows 7 ultimate 64 bit but looks like its not compatible with 64 bit windows. is there any way to play it on this version of windows?? help plz
Answer from: macho
I have a windows 7 ultimate 64 bit pc and still i was able to play it. you might have got a corrupted game or check for viruses.
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text:
Their result for The Sex In The Library Test ...
Dumb but sexy.
You scored 44 bookishness and 56 kinkiness!
Their Analysis (Vertical line = Average)
They scored 44% on bookishness, higher than 8% of your peers.
They scored 56% on kinkiness, higher than 17% of your peers.
All possible test results
Leave the premises.
Damn, why are you even IN the library? Well, you probably need to get some self-help books while you're here...bless your heart. Read more
Not the library type
Well, you don't really like library stuff...you do have a bit of a kinky side, though, so maybe you should go down the street to the peepshow. Read more
Dumb but sexy.
Hm, you sure do like sex, but you're definitely not into books and all that. You should probably seek your piece of ass elsewhere. But hey...rock on, kinky sex is where it's at! Read more
Unrefined Slut.
Hm, you're into kinky shit alright, but since you're not into books that much, the titty bar might be a better place for you to seek companionship. Read more
Maybe better to try reading up on some sexual techniques, since you seem to like books alright, but you don't really wanna have sex in the library or anywhere else. But you know, to every book its rea... Read more
A little shy.
Hm, you like books OK, you like sex a good bit...but you're not that much into sex in the library, now are you? Well, that's cool, maybe just go back to reading your book then. Read more
Hell yeah.
You love books, you're down with the kink...you'd almost definitely have sex in the library. Find a partner, find a good spot...and go for it. Read more
Alright, you love books, you completely dig great sex...and both at the same time is even better, n'est-ce pas? According to my calculation, you are SEX ON WHEELS...the wheels of a book truck, that is... Read more
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iPhone apps
SooPay P2P
Use UMPay's SooPay Person-to-Person payment app for the iPhone®, to instantly start making and receiving SooPay payments – with other users at physical locations! SooPay safely extends electronic payments to new venues, such as: · Street fairs ·….. Read more
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Bus tickets from Mafil to Loncoche are being sold from Buses Cruz del Sur.
The bus travel from Mafil and Loncoche takes approximately about 1 hour.
The distance between Mafil to Loncoche is (N/A) and you can choose between the services Semi Cama; dependent on the bus company you travel with (Buses Cruz del Sur).
Route from Mafil to Loncoche
When do you want to travel to Loncoche?
10/23/2016 10/24/2016 10/25/2016 10/26/2016 10/27/2016 10/28/2016 10/29/2016 10/30/2016 10/31/2016 11/01/2016 11/02/2016 11/03/2016
Information about the city Mafil
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I support staying in the EU but also support staying in the UK, what would be the point in him debating with someone with my views. Gold Dust, a video installation inspired by the search for the Higgs Boson or 'god particle', was selected for the Royal Society's Summer Science Exhibition this year. The value of much of the city's housing stock means changes will raise a fraction of what Glasgow has lost to cuts in recent years.
" Caroline Wood, a retired headteacher, said: "Over a long and varied career I have experienced how motivational the access to a changing range of books is to the development of pupils literacy and learning and, as they get older, access to a knowledgeable and qualified librarian. Xazha was inspired when a friend who was going through the hair loss side effects of chemo and was struggling to find something stylish and practical to wear. ??BaronFebruary 23rd, 2016 20:34 Herbert Thornton @ 16:53 The only mutation of God the barbarian can think of (an obvious one anyway) is reading the word backward, Herbert.
??The growth in fixed services was attributed to a larger residential customer base, as well as new corporate contracts secured during the year. Calcinator trade name for a slurry drying device consisting of a rotating cage filled with heat exchange bodies, through which the kiln exhaust gases pass, and into which slurry is sprayed. It also means, when you get to the slightly more surreal moments, like the career hungry trolls and the big reveal of Hogarth's actual mission, you are prepared for full on weirdness and so the whole thing??really delivers.


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The narrator of The Zahir is a bestselling novelist who lives in Paris and enjoys all the privileges money and celebrity bring. His wife of ten years, Esther, is a war correspondent who has disappeared along with a friend, Mikhail, who may or may not be her lover. Was Esther kidnapped, murdered, or did she simply escape a marriage that ... more on CAIRO BOOKSBuy it from CAIRO BOOKS
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Morgan Buildings Pools & Spas
2614 S 8th St., Rogers, AR 72758
(479) 631-4000
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Street address:
2614 S 8th St.
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ZIP code:
(479) 631-4000
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Miscellaneous Retail Stores, Nec
0.06 miles away
Special Trade Contractors, Nec
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- Retail Trade Miscellaneous Retail Miscellaneous Retail Stores, Nec
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|Annual sales estimate:
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More details about Morgan Buildings Pools & Spas
According to our records, this business is located at 2614 S 8th St. in Rogers (in Benton County), Arkansas 72758, the location GPS coordinates are: 36.292591 (latitude), -94.1271828 (longitude). Morgan Buildings Pools & Spas is categorized under Miscellaneous Retail Stores, Nec (SIC code 5999). Current estimates show that the unit has a sales volume of $1,005,000 and staff of approximately 5 people. You can contact the company by phone at (479) 631-4000.
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Rio Olympics might be a mess, but Tokyo 2020 has some cool high-tech plans
Driverless taxis for athletes and holograms for info.
Thu, Jul 07 2016
Clinton takes big step toward easing tensions with Sanders
With new college affordability plan, the presumptive Democratic nominee won praise from rival.
Thu, Jul 07 2016
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Wed, Jul 06 2016


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Daystate Mk4 Platinum , battery theory
View Single Post
3rd July 2010, 02:42 PM
Join Date: Feb 2010
Location: Nuneaton
Posts: 26
I have tried the swapped battery, Its worse. I changed the battery back, and shot both my Std Mk4 is and my AA s200. both far better groupings. in fact the S 200 the best of all of them a real confidence builder.
Gutted is close to the way I have felt. I know I am not the best shot. but I can put in ok scores. I and had to prove to myself that is wasn't me.
I dont want knock the gun just because its electronic. have had my Mk4 is over 1 yr and yes its had a couple of issues, but they were fixed quickly and its great now. The way to resolve this properly is to return it to Daystate so that they can check it over, I will do that next week. I do have faith in the Daystate warranty they are nice people and fix things when they are not right. there is no point in posting the it shouldn't happen type comments.
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Beautifully designed vinyl casement windows can add elegance and charm to any home in the Greater Toronto Area. Casement windows are particularly recommended to people who want attractive, yet, functional and practical windows. When you choose these stylish windows, you get perfect ventilation and also get to enjoy the beauty of the outdoors without compromising on the structural integrity of an operational vinyl window. The hinges in vinyl casement windows design allow this window to open to the left or right in a swinging motion that allows maximum fresh air and sunshine. Apart from that, these casement windows also offer other benefits that you would get from regular-style window designs. You can crank these vinyl windows outwards for ventilation and their maximum glass area allows you to enjoy nature optimally.
Windows And Doors Toronto, Vinyl Windows Replacement TorontoPosted by drakejones1 40 days ago (http://gtawindows.com)
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Private Island with 3 Pools, Private Beach, Tennis Court and More!$499 wk
The owner has been emailed.
To book this property, you need to complete your booking through checkout on the VRBO website. We can't protect your payment if we don't know you've booked through us. Learn more
This listing was first published here in 2014.
Date last modified - Monday, October 17, 2016


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Council of Europe: Recent reforms in Poland endanger rule of law
The advisory body of the human rights organisation Council of Europe has found that reforms made to the Polish Constitutional Tribunal on late 2015 endanger the rule of law in the country, after Poland asked the Council's Venice Commission to comment on the legal changes after parliament overruled appointments made to the tribunal by the previous government.
Reuters reports that the new parliament, controlled by the conservative Law and Justice (PiS) party after an October election, named new judges in December and the PiS-backed president Andrzej Duda swore them in soon after.
The measure, criticised illegal by the opposition, has already prompted the European Commission to launch a probe into the rule of law in Poland, while constitutional court itself ruled against the new appointments to its ranks.
In a draft opinion, obtained by the Gazeta Wyborcza newspaper as quoted by Reuters, the Venice Commission found that «… as long as the Constitutional Tribunal cannot carry out its work in an efficient manner, not only is the rule of law in danger but so is democracy and human rights.»
Ref: 220.127.116.1140
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Latvia receives historically highest score in latest Doing Business rating
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Raimonds Graube steps down as commander of Latvian Armed Forces
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Payments of benefits to be stopped for refugees who left Latvia
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Government urged to declassify Citadele Bank's sale
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Criminal process launched in relation to K.Barona Street repairs
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Sirens to be tested across all of Latvia
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This week to be rich with precipitation and cold in Latvia
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Latvia begins ratifying Paris agreement on climate change mitigation
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Estonia increases tax revenue by 6.8%
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Latvia's population declined by 4,636 this year
In the first nine months of 2016, Latvia's population decreased by 4,636 persons. This is because the number of deaths exceeded the number of births. In the corresponding period of 2015, population decline constituted 4,751 persons.
PUC: Latvijas Gāze remains obligated to provide third parties with access to gas infrastructure
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Estonia to combat large-scale imports of alcohol from Latvia
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obviously don't get out much and probably going for refit in Kalingrad or St Petersburg.
Pharmk973 @ 2016-10-11 21:07:18
@ 2016-10-11 20:24:00