UPDATED - Health Care - Let's See What Sticks

Update - Having read the comments to my original post, as well as doing more thinking and research, I have changed my views slightly. First, the individual mandate may be too extreme. A better alternative may be to give credits to households that qualify for government assistance that could be used to buy catastrophic coverage in the private market. Second, my desire to create a national market for health insurance would be two-fold, to make insurance portable for people moving or purchasing across state lines, and to allow greater competition at a lower regulatory burden for insurance companies. The ideas of individual mandates and national insurance markets are attractive on many functional levels, but I certainly wouldn't want to proceed in an unconstitutional manner. Aside from changing my first three point, which were certainly the most controversial of the bunch, and tweaking a few words here and there, I still thing these actions would be in the right step of moving people into a new era of viewing health care as a budgeted expenditure, and empowering them to make better individual decisions on the private market.

OK, I have been backed into a corner and will go ahead and outline my basic ideas for health care reform. These are by no means original to me, I have just collected/plagiarized/adapted them from elsewhere. I will perhaps provide links to sources and statistics as requested, but I wanted to get this out there. To respond to the most recent criticisms leveled against me, I think you will see that I am not placing my trust in government for so large an enterprise as health care. I am asking for government to create a framework and get the heck out of the way so people and the private sector can take responsibility for their own health without the current set of government created problems.

The extent to which I am seeking government involvement is as follows:

1. Eliminate the restrictions on the interstate sale of health insurance. This is a removal of burdensome regulation. Encourage states to adopt a common set of standards for a basic level of catastrophic insurance that would be portable and could be purchased from any qualified insurance company.

2. Replace 50 sets of regulation with a single set. Encourage states to adopt common regulatory standards. Drastically reducing and untangling existing regulations can not really be seen as "additional" regulation, unless you mean addition (of value) through subtraction (of quantity).

The goals of items 1 & 2 would be a much cleaner and clearer framework for a national insurance market. Repealing state laws and regulations that currently prevent insurance companies from competing across state lines would result in a lower regulatory burden, increased market opportunities (good for insurers) and increased competition (good for consumers). If not dramatically lowering costs, it would likely stabilize costs while increasing options. (Side note - As I understand it, the Ryan plan does not address this issue.)

3. Once a national market is in place, mandate encourage the purchase of "Basic" catastrophic health insurance plans that all insurers could sell as a commodity and/or loss leader for purchasers of additional coverage.

This would (ideally) be a portable, stand alone line of coverage, and one could switch at any time to another carrier offering a better deal, but everyone would be required to have this basic coverage. PLEASE NOTE - I am not talking about health care coverage in the sense of paying for physicals, flu shots, and your typical medical expenses. This is insurance to cover the risk of an unanticipated medical event (severe trauma, emergency surgery, stroke, organ failure, stroke, cancer, coma, etc.) that would, without adequate coverage, likely lead to destroyed life savings, massive debt, and/or bankruptcy. Most Americans would carry multiple layers of coverage, with the “basic” level being mandated, and any additional layers remaining optional. (An imperfect analogy would be car insurance, where liability coverage is mandated, and GAP, uninsured motorist, comprehensive, and others are commonly purchased additional options)

As to what gets deemed catastrophic, I share JB's concern (in the comments of the previous post) that elected/lobbied politicians would be all to meddle to the point that everything could be viewed as potentially catastrophic, so keeping the scope of any mandated coverage limited to managing the risk of personal/household catastrophe is important. The idea is to treat catastrophic coverage as a math problem, targeting the premium payment on a percentage (around 5%) of personal/household income, and providing coverage for health costs above a defined percent (15-25%) of annual personal/household income.

Do I wish there was another way? Certainly. But, as researchers, think tanks and policy makers across the political spectrum have learned (although they refuse to agree on it), a mandate of some basic form of coverage seems to be the only way to reduce “free rider” or “wait until sick to purchase” abuses.

4. Either eliminate (my preference) all tax breaks/deductions that deal with health care and health insurance, or make the tax treatment and incentives the same for all, individuals and employers.

5. Allow employers and individuals to form their own risk pools as they see fit (business networks, church congregations, Facebook groups, neighborhoods, whatever).

6. For all “extended” health insurance, repeal government mandates regarding what insurance companies must cover. Allow market variety and competition to determine what level or premiums and co-payments people are willing to pay for routine and planned medical care.

We are now talking not only about “basic” insurance coverage, but also all the “extended” health insurance, discount plans, prescription plans and health benefits that everyone should be allowed to choose and purchase on the private market. We know that currently employer health benefits are fully tax deductible, but individual health insurance is not. Not only is this unfair, it creates a burden on both employers (administration, tax prep) and employees (health benefits often overriding other job concerns). Employers can continue to offer “extended” health perks as benefits, but would not have to remain the dominant source through which they are made available or affordable. People should be free to associate in any manner they wish in order to better negotiate for themselves.

7. Mandate that health care providers have pricing for all basic services and procedures in plain sight and available upon request.

8. Encourage Health Spending Accounts (HSAs) that allow people greater freedom to make their own decisions on health care.

Put the price mechanism back into the health care market! This is perhaps the greatest sign that the current health care market is completely broken. People, especially those without “extended’ health coverage, are smart enough to make better decisions on quality and cost. It is incredible to think how much less Americans would spend on health care if they only had the choice, yet so few actually know the itemized or total cost of their last doctor's visit. Hint, it was A LOT more than anyone’s co-payment.

9. Enact serious Medicare and Medicaid reform and/or dismantlement.

10. Provide a safety net to this new system for those that can not afford it.

It is my position that if steps 1-8 were in place, several things would happen naturally as a result of human choice and market forces. First, the current level of health care spending by Americans would stabilize/decline as a much greater level purchasing decisions (of both coverage planes and health care services) would be placed in their hands to self-ration based on need, value, and return on investment. Second, the cost of services and insurance coverage will stabilize/decline. Giving individuals the ability to shop online for the doctor in town with the lowest prices (#7), and among insurance companies from across the country with the best rates (#1&2) enhances competition and choices.

Restoring basic functions such as supply and demand and price competition to the heath care industry are critical not only because our society will benefit from fewer bankruptcies (currently over 50% of bankruptcies are prompted by medical costs), increased access to care and lower costs of those services, but because we need to avoid the coming apocalypse of insolvency for Medicare, Medicaid, and Social Security.

Estimates range widely, but just using middle of the road numbers, current spending on Medicare, Medicaid and SCHIP is about $700B. To get to JB’s statistic of the US Government paying for over 50% ($1.2T) of all US health care expenditures ($2.4T), you have to add the active duty military Medical Corps and the Veterans Administration, along with a few other smaller programs. An important purpose of any meaningful health care reform should be reduce the government’s overall expenditures. Logic dictates that if everyone in America had “basic” catastrophic coverage, purchased in the private market, that private insurance would cover a much greater percentage of higher cost health care than it does today, reducing the government’s role as payer of last (or first) resort. And with a more prominent role for HSAs, individuals could also purchase a greater share of routine health care on a more open, price-sensitive, market.

Still, there are those that can not afford even the “basic” coverage or have much left over to fund a HSA. So how do we get from here to there?

First, I would favor a government plan that subsidizes the purchase of the “basic” catastrophic coverage outlined above for those that can not afford it. Current catastrophic insurance plans run from $1,200 per person to $3,000 per family. Basically, under may plan, any household making less than $60k would be expected to pay 3-5% of their income with the government making up the difference to purchase a plan. Again, using round numbers (and from 2006), there are about 70 million households that make less then $60k, so the government would step in and make up the difference between each of these household’s 3-5% contribution and the amount needed to purchase a “basic” plan. The cost would be a estimated $105 billion dollars. This is not an insignificant amount, but the question is whether this would reduce the government’s current annual outlay by at least the same amount, and hopefully by much more, whether we use the $700B (w/o military and vets) or $1.2T (with both) number. If so, we have achieved a form of universal coverage for a break even cost or better. I don’t have the resources to run definitive numbers, but I find it impossible to believe that is all medical costs above 20% of every household’s personal income were absorbed by the private market, from age 0 to dead, that government expenditure wouldn’t go down at least 15%. I am hopeful the savings would be great enough that a drastic overhaul and/or dismantling of Medicare and Medicaid becomes more politically viable.

Second, in order to promote HSAs, I would like to consider in greater depth a possible government match of HSA contributions for low and middle income households that would function much the same way of a company-matched 401k. Just a thought. I would like to see the cost to benefits numbers on such a program. Whether we are talking a 10% match for everyone up to a certain amount, or a greater (up to 25%?) match for targeted incomes, I would like more research on ways to encourage savings.

Is this welfare and redistribution? Sure, but I dare say it is less welfare, less redistribution, and would be loads more effective than the current patchwork of bloated government programs we are currently wasting money on. Are there other steps that I think can and should be taken? Sure, but I don’t know enough to have a definitive opinion on them, and I think the steps above would be a good first start. That said, I’ll leave you with a couple more suggestions that get thrown around a lot that would likely be worth considering.

11. Encourage a greater number of medical schools and enrollments. (Break up the AMA monopoly?)

12. Look as reform medical malpractice and tort laws. (Negligence should come at a price, but where are the limits?)

Healthcare: Further Proof

As if it is needed, more news of the current state of the Republican Party. I heard this story on NPR on the way to work this morning:

For Republicans, the idea of requiring every American to have health insurance is one of the most abhorrent provisions of the Democrats' health overhaul bills.

"Congress has never crossed the line between regulating what people choose to do and ordering them to do it," said Sen. Orrin Hatch (R-UT). "The difference between regulating and requiring is liberty."

But Hatch's opposition is ironic, or some would say, politically motivated. The last time Congress debated a health overhaul, when Bill Clinton was president, Hatch and several other senators who now oppose the so-called individual mandate actually supported a bill that would have required it.

In fact, says Len Nichols of the New America Foundation, the individual mandate was originally a Republican idea. "It was invented by Mark Pauly to give to George Bush Sr. back in the day, as a competition to the employer mandate focus of the Democrats at the time."

The 'Free-Rider Effect'

Pauly, a conservative health economist at the University of Pennsylvania's Wharton School, says it wasn't just his idea. Back in the late 1980s — when Democrats were pushing not just a requirement for employers to provide insurance, but also the possibility of a government-sponsored single-payer system — "a group of economists and health policy people, market-oriented, sat down and said, 'Let's see if we can come up with a health reform proposal that would preserve a role for markets but would also achieve universal coverage.' "

The idea of the individual mandate was about the only logical way to get there, Pauly says. That's because even with the most generous subsidies or enticements, "there would always be some Evel Knievels of health insurance, who would decline coverage even if the subsidies were very generous, and even if they could afford it, quote unquote, so if you really wanted to close the gap, that's the step you'd have to take."

One reason the individual mandate appealed to conservatives is because it called for individual responsibility to address what economists call the "free-rider effect." That's the fact that if a person is in an accident or comes down with a dread disease, that person is going to get medical care, and someone is going to pay for it.

"We called this responsible national health insurance," says Pauly. "There was a kind of an ethical and moral support for the notion that people shouldn't be allowed to free-ride on the charity of fellow citizens."

Republican, Democratic Bills Strikingly Similar

So while President Clinton was pushing for employers to cover their workers in his 1993 bill, John Chafee of Rhode Island, along with 20 other GOP senators and Rep. Bill Thomas of California, introduced legislation that instead featured an individual mandate. Four of those Republican co-sponsors — Hatch, Charles Grassley of Iowa, Robert Bennett of Utah and Christopher Bond of Missouri — remain in the Senate today.

The GOP's 1993 measure included some features Republicans still want Democrats to consider, including damage award caps for medical malpractice lawsuits.

But the summary of the Republican bill from the Clinton era and the Democratic bills that passed the House and Senate over the past few months are startlingly alike.

Beyond the requirement that everyone have insurance, both call for purchasing pools and standardized insurance plans. Both call for a ban on insurers denying coverage or raising premiums because a person has been sick in the past. Both even call for increased federal research into the effectiveness of medical treatments — something else that used to have strong bipartisan support, but that Republicans have been backing away from recently.

'A Sad Testament'

Nichols, of the New America Foundation, says he's depressed that so many issues that used to be part of the Republican health agenda are now being rejected by Republican leaders and most of the rank and file. "I think it's a sad testament to the state of relations among the parties that they've gotten to this point," he said.

And how does economist Pauly feel about the GOP's retreat from the individual mandate they used to promote? "That's not something that makes me particularly happy," he says.

As Reagan, Buckley Jr., and countless others have said, I didn't leave the Republican Party, the Party left me. I have always been an independent, but used to default to the Party of self-responsibility, fiscal conservatism, entrepreneurship, humble foreign policy, and individual civil liberties. I have no use for a Party that has made golden calves of Medicare, unfunded spending, parasitical banks, war, torture, and Homeland Security. And those that would scream "Tea Party!" are even worse. The movement started by Ron Paul has quickly dissolved into a terrible combination of populism, anti-tax shrieking, and jingoism. Just look at the competition Paul himself is facing for re-election.

With respect to health-care, of course I would in theory always favor market solutions over government intervention. However, when the last century's most brilliant free-market advocates see a clear role for government in health care where profit motives and markets fail, and their arguments have stood the test of time, I am inclined to listen:

A more radical reform would, first, end both Medicare and Medicaid, at least for new entrants, and replace them by providing every family in the United States with catastrophic insurance (i.e., a major medical policy with a high deductible). Second, it would end tax exemption of employer-provided medical care. And, third, it would remove the restrictive regulations that are now imposed on medical insurance—hard to justify with universal catastrophic insurance.

Milton Friedman, Hoover Digest 2001

And:

Nor is there any reason why the state should not assist the individuals in providing for those common hazards of life against which, because of their uncertainty, few individuals can make adequate provision. Where, as in the case of sickness and accident, neither the desire to avoid such calamities nor the efforts to overcome their consequences are as a rule weakened by the provision of assistance – where, in short, we deal with genuinely insurable risks – the case for the state’s helping to organize a comprehensive system of social insurance is very strong…

…Wherever communal action can mitigate disasters against which the individual can neither attempt to guard himself nor make the provision for the consequences, such communal action should undoubtedly be taken.

Friedrich Hayek, The Road To Serfdom (Chapter 9)

Politics getting in the way of problem-solving, who could have guessed? If I were constitutional dictator, I would evoke the commerce clause to standardize health insurance regulations across all 50 states, the equal protection clause to end unequal advantages for employer-provided insurance, and the general welfare clause to provide/mandate catastrophic health insurance (with high-deductible) for everyone through competing private co-ops, non-profits, and for-profits.

Finally, as a society, we need to re-define the concept of health-care coverage and insurance. I am amazed that people complain of $20-25 co-pays while the national average monthly expenditures on coffee ($74), hair styling ($66), cable television ($60), and cell phones ($70) far surpass those co-pay expenses (take a look at this chart for how many things we spend more money on than health insurance). That, to me, is a problem of entitlement and priorities that government can not fix.

Criminals and Civility

I stumbled on the Christianity, philosophy, and chess blog "you think, i thought, who confirm?" and specifically a post where author Luke Leong provides famous quotes on the philosophy of criminal law:

"The degree of civilisation in a society can be judged by entering its prisons." - Fyodor Dostoyevsky, The House of the Dead

.....

"The quality of a criminal justice system is an important measure of the value of a political community. Apart from waging war, no decision made by the state is more significant than its judgment about what conduct should be proscribed and how severely to punish it." - Douglas Husak, Overcriminalisation: The Limits of the Criminal Law

.....

The mood and temper of the public in regard to the treatment of crime and criminals is one of the most unfailing tests of the civilisation of any country.

A calm, dispassionate recognition of the right of the accused, and even of the convicted criminal - a constant heart-searching by all charged with the duty of punishment - a desire and eagerness to rehabilitate in the world of industry those who have paid their due in the hard coinage of punishment: tireless efforts towards the discovery of curative and regenerative processes: unfailing faith that there is a treasure, if you can only find it, in the heart of every man.

These are the symbols which, in the treatment of crime and criminal, mark and measure the stored-up strength of a nation and sign and proof of the living virtue in it.

- Winston Churchill, Speech in the House of Commons (1910)

Balancing the rights of the accused, the dignity of all individuals, a respect for the rule of law, and civil order has always been difficult, but in the hundred years since Churchill spoke those words, it is clear to me that America has drifted a bit too far down the "tough on crime" road. The Innocence Project would not be in such demand if juries (in representing and reflecting the nature of our society) were not so quick to replace the standard of "beyond a reasonable doubt" with "probably did something worth going to jail (or dying) for." Another example are the numerous variations of "three strikes and life" legislation that slams the door shut on rehabilitating and nurturing the heart of so many.

Becase whiteys pass and shoot three-pointers?

From NPR, I just had to post this:

This idea offends so many people on so many levels that I can't believe it will get anywhere:

A promoter says he's going to start up a whites-only professional basketball league with teams in 12 Southern cities.

And Don "Moose" Lewis says there's nothing hateful about the idea.

"I don't hate anyone of color," he told the Augusta Chronicle. "But people of white, American-born citizens are in the minority now. Here's a league for white players to play fundamental basketball, which they like."

Players would have to be "natural born United States citizens with both parents of Caucasian race."

Rick Chandler at NBC Sports' Out of Bounds blog says he "made a couple of calls to make sure this isn't some sort of prank, and sadly, it's indeed legit." Then, he adds:

OK global warming, we're pretty much done here. We thought we were making progress, but you can go ahead and cook us up. Just try and spare the dolphins; they're smart.

WJBF-TV in Augusta aired this report:

In idea so backwards and laughable that even ol' Augusta finds too objectionable - I didn't know that was possible. I kid, I kid, I grew up in Disgusta, it does have its advantages.

Call the Po Po!

Leave it to the French government, which if it has its way, will make yelling at or insulting your spouse or roommate a crime:

A bill being put forward by Nicolas Sarkozy's government would make "psychological violence" between married or cohabiting couples a matter for state intervention. It's a puzzling and problematic idea, for all manner of reasons.

For starters, there's the question of defining an act of psychological violence: as it stands, the legislation would appear to cover everything from nagging, to false accusations of infidelity, to sustained campaigns of verbal abuse, to a failure to supply the correct answer to the question: "Does my bum look big in this?"

I will start this with a statement and disclaimer. I love my wife, and I don't know anyone that has a fundamentally stronger relationship than the Mrs. and I. We are happy as husband and wife, and are also great friends who deeply enjoy sharing life together. That, and the following few paragraphs are (kinda sorta) tongue in cheek.

Having said all that, I AM half-Italian. Multiplying the decibel level, turning red in the face, and waving my limbs violently is pretty much my genetically programmed default setting for having a discussion. Add to this the faulty on/off switch on my sarcastic remarks generator, and the result is a propensity for unfortunate missteps when it comes to domestic disputes.

Lest you call me a monster, let me assure you that I married the right woman, and Mrs. Hommes gives as good or better than she receives. I knew I had to find a strong woman that could keep me in my place, and apparently you have to be careful what you ask for, because I certainly got it and then some.

Overall we have a complimentary and functional, even if messy at times, communication style. By wearing our relationships on our sleeves, we always know where we stand with one another, nothing is ever left unsaid (good or bad), and we are quick to fix problems and not allow them to fester or grow. As we get mature together, we are mellowing out a bit and smoothing out more and more of the rough edges everyday, but let's just say we are both still glad we don't live in France!

Avatar

Everyone on the internet seems to see in this film whatever they are looking for, be it religious, racial, economic, political, or cultural. I have not seen it, and really have not had the desire to go watch it up to this point, but at the same time, as was the case throughout my un-cool childhood (not that the situation is any different now), there is the fear of passing over this cultural phenomena, be it for better or worse, and then forever not understanding all future references.

So two questions: 1) Did I not just write one of the most convoluted sentences ever? and 2) Should I go see Avatar?

Big Business Hearts Big Government

Per the CATO blog:

The late George Stigler, winner of the Nobel Prize in economics, is famous in part because of his work on “regulatory capture,” which occurs when interest groups use the coercive power of government to thwart competition and undeservedly line their own pockets. A perfect (and distasteful) example of this can be found in today’s Washington Post, which reports that the IRS plans to impose new regulations dictating who can prepare tax returns. Not surprisingly, the new rules have the support of big tax preparation shops such as H&R Block and Jackson Hewitt, which see this as an opportunity to squeeze smaller competitors out of the market. The IRS and the big firms claim more regulations are needed to protect consumers from shoddy work, but this is the usual rationale for licensing laws and other government-imposed barriers to entry and the Institute for Justice has repeatedly shown such rules are designed to benefit insiders rather than consumers.

When governments and corporations proclaim they have come up with a win-win them, you can almost be certain the average citizen is the loser.

Human nature is the same whether we talk about governments, corporations, organizations, or individuals - even if one's optimal role, size and limitations could be known and defined, there remains the ever-present temptation to go a littler further, wield a bit more influence, gain a bit more control, tweak the rules in one's favor, and/or grow a little richer. When governments are not involved, and no laws are broken, we call this competition, which is great. When businesses lobby/buy the use of government force, however, we should call it for what it is, corruption.

I admit it, I laughed

Judging from the reaction across the internet, I was far from alone in noticing the cowbell girl during the halftime of the Tostitos Fiesta Bowl. But as SB Nation and EDSBS have since reported, the Boise State Cowbell girl is blind. So is it OK to still think this is hilarious?

Welcome to The Jungle

The more things change, the more they stay the same, or so Upton Sinclair would likely say were he still alive.

Mrs. Hommes thinks I am crazy for buying more expensive cuts of beef in order to grind my own meat at home to make hamburgers. Perhaps, but my defense is pretty straightforward: It's more fun, I don't eat burgers often enough for the extra cost to become an issue, the burgers taste better when the exact cuts and meat:fat ratios can be controlled, and most importantly, I don't have to eat the ammonia treated and e. coli tainted ground beef that corporate agribusiness produces:

Stephanie Smith, a children’s dance instructor, thought she had a stomach virus…

Then her diarrhea turned bloody. Her kidneys shut down. Seizures knocked her unconscious. The convulsions grew so relentless that doctors had to put her in a coma for nine weeks. When she emerged, she could no longer walk. The affliction had ravaged her nervous system and left her paralyzed.

Ms. Smith, 22, was found to have a severe form of food-borne illness caused by E. coli, which Minnesota officials traced to the hamburger that her mother had grilled for their Sunday dinner in early fall 2007…

The frozen hamburgers that the Smiths ate, which were made by the food giant Cargill, were labeled “American Chef’s Selection Angus Beef Patties.”….ingredients came from slaughterhouses in Nebraska, Texas and Uruguay, and from a South Dakota company that processes fatty trimmings and treats them with ammonia to kill bacteria.

So before you buy that next package of ground beef or box of frozen patties, be sure to ask yourself if you feel lucky.

As mentioned in the above linked Naked Capitalism blog post as well as the two New York Times articles, feces contamination is the culprit, so the amount of surface area exposed inside a meat processing facility is a key risk factor, and this risk must be multiplied by the number of animals and processing plants that make up the ground beef. A home grind drastically lowers the numbers on both sides of the equation, so it certainly reduces, if not completely eliminates, the chance of e. coli in my burgers.

For those that do not want to go through the added hassle of grinding their own beef, but don't necessarily like the idea of eating ammonia treated beef trimmings as part of their burgers, there are other steps that can be taken. The first is to find a trusty local butcher shop that buys whole sides of beef and grinds their own beef in the store. If this is not feasible, then buying a whole chuck or sirloin roast at your megamart and having the roast ground in the store is another option. Finally, many grocery chains, Publix included, will take the steaks, roasts, and other large cuts that are within a couple days of their "sell by" dates and grind them in the store, and sell them as "market" ground beef. This ground beef will NOT contain fat percentage markings, as the selections will vary daily and there is no in-store inspector. Still, if you ask the butcher, they can tell you when the meat was ground, and often tell you what cuts made up the bulk of the grind. If they talk, you will usually be happy to learn that the expensive and/or organic selections make up the bulk of the selection, as turnover rate tends to vary the most on these items. The cost is just as low or lower than the other ground beefs, and will contain no ammonium treated trimmings, and tastes very fresh as long as it used within a couple of days. With any option, the cleanliness of the grinding equipment should also be questions, but even Mrs. Hommes, who loves to accuse me of being a food snob (justifiably so in some cases), is willing to make a little extra effort to upgrade the selection of ground beef found in our frig.

Are the chances of being infected by e. coli incredibly small? Absolutely. Does that mean that meat producers are doing everything they can and should be doing considering the risks versus profits? Absolutely not.

From the Reading Chair

In using the New Year's weekend to finally start my current reading assignment in earnest, I came across this rather interesting excerpt:

There came a time (Early Modern) when, apparently, life lost the ability to
arrange itself. It had to be arranged. Intellectuals took this as
their job. From, say, Machiavelli's time to our own this arrangement has been the
one great great gorgeous tantalizing misleading disastrous project.

- Humboldt's Gift, Saul Bellow