Know
What Every American Should Know
Knowledge is our best first step
to establish universal health care.
The Basics:
What Every American Should Know
What we have:
Affordable Care Act (Obamacare). Every other free-market country implemented universal health care, health care for all. On average, the other countries pay 40% per person of what we pay for health care, but they cover 100% of their citizens' needs. While we pay 250% times what they do, we have tens of millions of Americans who have no health insurance or who are underinsured. That situation will remain the same after Obamacare is implemented. Obamacare kept all the kinds of bureaucracy that we already had: government, health insurance companies, and our related bureacracy, and it added more bureaucracy.What we need:Results. This situation causes many hardships for individuals and families and hurts our economy. Our out-of-control costs make us less competitive in the global marketplace than we should be, causing job losses. Our dramatically lower physician visits than other countries is a contributor to our poor life expectancy, maternal mortality and amenable mortality.
Improved Medicare for All. We need efficiency, which is what universal health care provides. However, we can establish the highest degree of efficiency, the best universal heatlh in the world with one payer, one plan and our large country. Nobody will be left out, and citizens of any age will be covered.
Results. Having one public fund to cover everyone results in more freedoms, better health, a better economy and more jobs.
How to get it. We have an efficient and effective plan to get Improved Medicare for All. It's called our "Help Get Care Plan." The proposed U.S. universal health care is bill H.R. 676 in the U.S. House to implement national single-payer health care, Improved Medicare for All.
The Details:
What Every American Should Know
The Solution: the Need for Universal Health Care and its Incredibly Positive Results
Frequently Asked Questions FAQs
Testimonials — from Americans abroad
Introduction
Situation
The United States has excellent medical facilities and medical professionals. However, our overall performance related to using those facilities and professionals is very poor, and it is getting worse over time.
As you will learn by reading this "Know" web page:
— Comparisons to other countries regarding cost per person and health care outcomes show that the United States performs poorly.
— We are not getting to the doctor. Our access to health care is poor due to our complex, inefficient and very costly health care.
— We have a health care system that is NOT for all. The Affordable Care Act, Obamacare, is not universal health care, so it is referenced only in the FAQs of this web page.
— More than a third of us have either no health insurance or are under-insured.
— Our health outcomes, such as life expectancy, are not only poor, but are getting worse.
All other free-market countries have health care for all systems, often called "universal health care".
The cost burden on us in our current health care system:
— is more than twice as high as it should and could be on a per person basis and
— has been out-of-control for decades.That heavy cost burden:
— causes our poor access to health care
— which, in turn, causes poorer health results,
which often include our premature deaths from preventable causes.A Better Way: Efficiency
When we cover everyone and spend much less ...
by implementing the efficiency of ONE payer and ONE plan,
we will get the benefits of
— more job opportunities
due to lower labor costs for employers
and due to more customers for employers
from having more Americans with money to spend
— peace of mind due to ...
... being able to get health care with no
costs at the time of getting care and no
major medical bills
... the new freedoms we will have related to
making health care and life decisions.
The Problems
We spend too much for health care in the United States,
and we have gotten very poor results,
especially considering that other countries get
twice as much for less than half the price.
The cause? Inefficiency from our bureaucracy and complexity.
The Situation: Our High Cost
The United States is uniquely alone with out-of-control health care spending.
(click for larger image)
National Health Spending as
a % of G.D.P.
( more )
(similar graph Canada vs. U.S.A.)Our country is the only free-market country with out-of-control health care costs.Our problem started in the 1980's.Our health care costs increased dramatically, shortly after two things occurred:
— The U.S. started an increased focus on the use of private health insurance companies via a concept called “managed care” and the establishment of health maintenance organizations (HMO’s).
— Most other high-income free-market countries completed implementations of their universal health care between 1883 and 1975. They implemented their cost-efficient universal health care to cover all of their citizens. Even the two low-income free-market countries have now been implementing universal health care, leaving the United States the only free-market country without health care for all of its citizens.The Result: Our Very Poor Access and Poor Health Outcomes
Lack of access to health care.
Poor access means the inability of many of us to go to the doctor due to
— our general fear about the high cost of health care,
whether we are uninsured or underinsured or
— our specific fear that the next medical bill
we receive may cause an excessive burden our family.Note that our number of physician visits per year is low compared to other countries.
Note: The "Average of Six" for this and the
similar bar charts that follow is a
population-weighted average.Our lack of access to health care is caused primarily by the high cost of health care.
The high cost of health care is caused primarily by our inefficient, complex system, as highlighted below at "The Primary Cause".
Poor health outcomes.
The additional unfortunate results of poor U.S. health outcomes, such as our poor life expectancy and poor maternal mortality, are covered in the "The Need and the Incredible Results" section, below, from the perspective having universal health care help change those poor health outcomes into the incredibly positive results.Some Specific Results of our very poor access and our very high costs
Hardships. A long list of different types of hardships is the overall result across our U.S. population.What can and does happen due to our not going to the doctor due to concerns about the cost.Paul Hannon died at age 45: ruptured appendix; August 3, 2006.
"He had a little girl on the way," ...
"He didn't want the added burden of an ER visit to hang on their finances. He thought 'I'll just wait,' ..." — CNNKyle Willis died at age 24: complications from a tooth infection; September 3, 2011.The impacts of increased cost and the resulting lack of access are getting worse and worse.Americans have been and are losing the benefit of health insurance from their employers. That is very costly, either in money ... because the employee must purchase health insurance themselves ... or in health, as indicated by the examples above.There has been a steady decline in employer-sponsored health insurance.Employer-sponsored insurance over time
Increasingly more of a burden on employees. Even when and where health insurance is provided, the employers are forced to put more and more of the cost burden onto the employees.Why? Companies either literally cannot afford it or because the cost is cutting too much into company profits that their stockholders expect.The Primary Cause
The Primary Cause: Inefficiency from Our Bureaucracy and Complexity
Within the United State we have a complex way to pay for health care among three types of bureaucracy.We must eliminate the unnecessary administrative functions and reduce the size of the bureaucracy itself.
We can achieve the necessary simplicity when we implement Improved Medicare for All (explanation) with single-payer health care.
The benefits of the improved efficiency is over $400 billion per year that is being spent on unnecessary administrative functions, and the activities that result from those functions, instead of health care.
(Update: Economist Gerald Friedman stated in December 2012 that the efficiency difference is conservatively $500 to $600 billion per year.)About Complexity and Simplicity
What we have today:
complexity and 69% efficiencyHundreds of payers within three types of bureaucracy:
— hundreds of government programs
— over 1300 health insurance companies
— thousands of related activities
Hundreds of plansResult: Complexity with 69% efficiency.What we'll have with Improved Medicare for All:
simplicity and 95+% efficiency (95% or better):One payer: one public agency
One plan: all medically-necessary careResult: Simplicity.
It IS that simple to accomplish the most progress!
We must establish efficiency via simplicity
with the best universal health care:
U.S. single-payer health care,
Improved Medicare for All.
We can have the best universal health care as the result.
The SOLUTION:
the Need for Universal Health Care
and Its Incredibly Positive Results
About Universal Health Care
What is it? Universal health care within a country means that there is a system that provides for every citizen to have access to high quality health care at a reasonable cost. The focus on everyone having access to health care automatically establishes a focus on efficiency via simplicity, which results in the low cost.
Who has it? All other high-income free-market countries have some version of universal health care.
When did they get it? Those countries implemented their health care for all systems between 1883 and 1975.
Six countries are top performers ... with a combined total of over 250 years experienceTo compare the United States' performance to other countries, we selected six top free-market country performers regarding minimizing deaths due to preventable causes. That is called "amenable mortality". Those top-performing countries are France, Japan, Australia, Spain, Italy and Canada from among the 19 countries studied by researchers at the University of London.
As of 2012 the number of years of experience
with health care for all are as follows:
France-67, Japan-51, Australia-38,
Spain-26, Italy-34, Canada-40.Among the 19 countries of the study the United States fell from 15th to 19th position between the 2003 report and the 2008 report.
We can have the best universal health care by implementing H.R. 676.
Our national single-payer health care, Improved Medicare for All, is defined by U.S. House Bill H.R. 676, which is the basis for the best universal health care. Why? Because we'll have the best efficiency from having the highest degree of simplicity.
How will we accomplish enough health care efficiency in order to be the best?
Excellent efficiency comes from having these advantages:
A. One health insurance plan
B. One public agency payer, the "single-payer"
C. The corresponding elimination of unnecessary administrative activities and functions among our three types of bureaucracy.
D. The use of our ability to be the most powerful negotiator of drug and equipment prices due to the size of our country along with us having only one payer.To see a side-by-side comparison of our current system and
Improved Medicare for All, go to the "Best" web page.Should we conduct a new study of the other countries's universal health care systems and copy one of their systerms and apply it to the United States.
No. We've already done the comparisons to our plan, which is the best. See the information provided at the "Best" web page.
Example: A country with one of the best set of health outcomes is France. However, we know that France does not have the advantages listed as A through D, listed above. They have hundreds of non-profit sickness funds, making our one-payer system much better.
The Incredible Results
Efficiency provides incredible results by getting more, paying less and covering everyone.
1. Get more.
Better health outcomes due to these factors:
— We will have solved the problem of poor access by now having access for everyone.
— When we do need care, we will have access to all medically necessary care.
A. Improvement of our poor life expectancy compared to other countries
(click for larger image)
Life Expectancy at Birth
More information and charts are
available about life expectancy and
our poor performance globally.
B. Improvement of our performance regarding preventable causes of death under age 75.We'll save some or all of the 101,000 unnecessary deaths compared to the top three performing countries: France, Japan, Australia.
(click for larger image)
Amenable Mortality
Deaths per 100,000 population
under age 75 due to
preventable causes (not diseases as seen on bar chart)
( more )
C. Improvement of our maternal mortality: the number of deaths among women during pregnancy, childbirth or in the 42 days after delivery.
Our efforts to get universal health care could be called the "Save Our Mothers" campaign! Look at the huge difference between the United States and the other six countries!
D. More businesses. More job opportunities.Lower health care costs (below) will be a basis for not only the recovery of businesses and jobs, but also the addition of businesses and jobs.Note: Companies will not have to spend money managing the employee benefit of health insurance. The companies will observe that U.S. health care costs will not only drop, but will be in control and globally competitive with other countries. Those factors mean that the cost of operations for business units the United States will be competitive with other countries.E. Peace of mind.Americans will be able to make health care decisions and life choices without unnecessary financial, physical and emotional stress.This would compete for first place for being an incredible result of health care for all. For those who have not experienced it or know of it, the feeling of peace of mind was overwhelming to me when I lived and worked abroad. I can sense it every time that I speak with a citizen of another country who expresses their amazement to me about the United States' poor system. - Bob
2. Pay less money and eliminate unnecessary hardships.
Our potential for reducing costs by half or more is indicated in the following graph.
Lower U.S. health care spending will contribute to a healthier economy, including higher individual and family average net incomes.
We will no longer have the burden of uniquely out-of-control health care costs, causing so many hardships.There will be no major medical bills to patients.The natural result of no major medical bills is that patients can all keep their homes, along with not needing to declare bankruptcy. You can read the testimonials of Americans who have experienced the reality of no major medical bills when they lived and worked in other free-market countries.
(click for larger image)
Bankruptcies Due to Medical Bills:
Essentially zero medical-related bankruptcies
in the other six countries..( more )There will be less spending related to health care for all levels of government, such as the savings that will be realized for a individual state.
3. Cover everyone.
Everybody in. Nobody out.
Frequently Asked Questions
FAQs
Below are selections from our entire set
of Answers to questions and concerns.
Legislation
Is there proposed Medicare for All legislation in the U.S. Congress?
Yes: U.S. House bill H.R. 676 proposes one plan and one payer.
[Bernie Sanders Senate bill S. 915 proposes at least 51 payers. Therefore, we need a bill equivalent to H.R. 676 introduced in the U.S. Senate.]
Impact of Improved Medicare for All on Us
What medical care will we get with Improved Medicare for All?
All medically necessary care. Examples: primary care; inpatient; outpatient; emergency; prescription drugs; equipment; midwives; long term care; palliative; podiatric; mental health; dentistry; hearing, vision; chiropractic; substance abuse treatment as per H.R. 676.
How will we get access to health care?
We will show our card and get care.
How will the costs of health care change and what will be the results?
Based on the cost per person results of other free-market countries and based on our system being the best, we will cut costs by half or more. We will eliminate unnecessary administrative functions and negotiate drug and equipment costs. The results of cost-cutting include these: no premiums, co-pays, deductibles, or major medical bills, such as those that result from coinsurance.Businesses, states, counties, cities and school boards will no longer be burdened with the topic of managing health insurance as an offered benefit ... and will no longer be burdened by an excessive cost of providing it to employees.Health care with dignity: no hardships, fund-raisers or applications to charities.However, the health care system will need to be funded. Funding methods will be decided by Congress with input from experts and, if it’s necessary, from millions of us via our campaign! See the next question for more about funding.See: Cost per Person, BestHow will Improved Medicare for All be funded?Funding methods will be decided by Congress. One possibility is a combination of the following methods, as per the proposal within H.R. 676: employee Medicare tax; employer Medicare tax; increase in personal income tax for top 5% of income earners; existing government funding sources; and small taxes on stock/bond transactions and unearned income.In return we will have no premiums, co-pays, deductibles, or major medical bills, such as those that result from coinsurance, and the resulting financially-caused hardships.Is it “socialized medicine”?
No. We’ll have privately-delivered health care that is publicly-paid. Family doctors with private practices will be promptly paid by the public agency.How will this impact jobs? mforall.org/p/morejobs
Positively. Lower labor costs and other lower cost of operations will result from lower health care costs. For example, employers will no longer need to have a staff person(s) working on managing the health insurance benefit for their employees.What about the jobs eliminated among our three health care beauracracies when the new system is implemented?
Funding will be provided to retrain workers. Job transition benefits will apply to “clerical, administrative, and billing personnel in insurance companies, doctors offices, hospitals, nursing facilities, and other facilities whose jobs are eliminated due to reduced administration”, as per the proposed legislation H.R. 676. There will be many job opportunities from the jobs that will be recovered and added due to the U.S. being more globally competitive in many businesses. Those opportunities will result from our having more globally competitive heatlh care costs.What about the impact on our family physicians?
More time for patients. Higher job satisfaction. Higher net income: lower costs for liability insurance and billing and not dealing with multiple payers.
Impact of Improved Medicare for All on Our Country
Is the current U.S. health care the best in the world?
For those who can pay for it, our health care is the best. But when compared to other free-market countries the U.S. performance is very poor. Consider our 2010 study of France, Japan, Australia, Spain, Italy and Canada: they pay less than half in health care spending per person, see physicians more than twice as often, cover everyone and have better overall health outcomes.
Why is the USA 19th out of 19 countries the ability to minimize deaths under age 75 due to preventable causes?
Extremely high costs are a barrier. People hesitate to go to the doctor due to cost. The root cause of those high costs is unnecessary and/or duplicated administrative functions within our complex system of hundreds of government programs, over 1300 health insurance companies; and thousands of related activities. mforall.org/p/791
What about the Affordable Care Act of 2010, also called Obama's health care law or simply Obamacare?
The law is helping some people. However, it kept all of our complexity and added more. The result will be higher costs, higher taxes, government intrusions, and tens of millions uninsured or underinsured. We can do much better with Improved Medicare for All.
mforall.org/p/march2010lawWon’t innovation be hurt?
No. It will be alive and well, just as in other free-market countries.
— 1910: laparoscopic surgery: Sweden
— 1968: Gamma Knife radiosurgery: Sweden
— 1972: CT scan: England
— 1981: laproscopic appendectomy: Germany
— 1999: juvenile diabetes treatment by transplanting pancreatic cells: Canada.I don’t want a government-takeover of health care.
Your family doctor will be able to maintain their private practice. Many government programs will no longer be needed in the simpler system.
People should take care of their health.Yes, but everyone needs health care at some point, whether a person is responsible or not for their accident or disease.
Concerns
If it is so great, why don’t we already have Improved Medicare for All?
There has been and is strong opposition by a small number of special interests. The expensive media campaigns of the opposition have been influencing our opinions for many years. We must inform ourselves to be able to recognize those attempts to control our opinion and make those campaigns worthless in terms of controlling our opinion. Then we must communicate in a unified way with the campaign to get support from our elected U.S. officials by telling them in massive numbers that we want national single-payer health care, Improved Medicare for All.
What is the best action to take as an individual?
— Help our knowledge. Be informed. Sign up to be a Health Care Patriot. Tell others.
— Helpl our numbers. Participate in the campaign.
How can we help get Improved Medicare for All?
Follow the Steps to Success, doing these actions:
— Be informed, doing a careful read of this web page: "What Americans Should Know".
— Read the testimonials of Americans who live and work in other free-market countries.
— Know where to get answers to questions and concerns.
— Sign up and participate in the campaign: be united in our communications to Congress.
— Inform others with this web page, preferably in very small groups, and then invite the informed Americans to sign up.
The U.S. is too large to have health care for all.
The larger the population, the less the financial risk for any one person or family and the greater the leverage to negotiate for reasonable prices on drugs, medical equipment and health care. We will no longer subsidize other countries’ low prices for medicines, as we do now by our failing to negotiate prices. We already have years of experience with establishing excellent negotiated prices via the Veterans Administration. We have years of experience with single-payer via the Medicare system that existed between 1965 and 2003 when the U.S. Congress partly-privatized it. So this is not something new for the United States.
Summary: We have excellent experience by doing this for some, those over 65.
We can and will confidently do this for all.
We must address tort reform first.
The best way to reduce malpractice premiums is to have Medicare for All. There is no reason to sue for a lifetime of health care, because everyone will have health care. Malpractice lawsuits will only be for the injury, not for the cost of health care for the remainder of the patient’s life.
I’m afraid of such a big, risky change.
The change will reduce our risk of hardships dramatically and eliminate our risk of medically-caused bankruptcies. Health care for all provides improved physical, mental, and financial well-being plus peace of mind about the cost of health care.The Start-Up and More
Will our health care be like that of Canada or France or Germany?
No. It will be better: better simplicity, efficiency and effectiveness.
One plan. One public agency. mforall.org/p/Best
Don’t Canadians flock to the U.S. to get good health care?No. Canadians overwhelmingly like their health care, so the majority of Canadians would either laugh at this "picture" of them flocking to the U.S. ... or be insulted by it. Research shows that few Canadians seek medical care in the United States. Americans who live and work in Canada and other countries have written positive testimonials about the health care for all systems of those countries.
Aren’t there serious problems with Canada’s health care?Canada is recovering fine from a period of under-funding. Their health care has an incredibly high 86% approval rating by Canadians. They want refinements and problem-solving related to their health care to be made via public, not private, solutions. mforall.org/p/Canada
Will there be enough doctors and nurses?Yes. Currently many doctors and nurses are employed in non-health-care job positions or have retired or will retire early due to frustrations in dealing with the current complex system. More young people will go into the health care profession due to a better work environment.
Don’t patients flock to the U.S. for health care?No. The trend is that three times more Americans will be leaving the USA for care than foreigners will be coming to the USA. We’ll help our economy, jobs and health by keeping patients here.
See Our Entire Set of Answers
Do you have more questions and concerns?
We provide so many answers to questions and concerns that it may take some extra seconds for your computer to load the web page! mforall.org/p/Answers
Learn from our entire set of Answers.
Please take a moment to consider what your questions and concerns are and write them onto a piece of paper. Then go to the answers web page where you can get answers to those questions and concerns or read all of the Answers to help maximize your knowledge about improved Medicare for All.Again ... the answers page might take a while to load (display), especially on a slower computer.
Testimonials
from Americans Abroad
Americans who live and work in other free-market countries
provided their testimonials about universal health care.
These are a few excerpts from some of our many testimonials.Australia 3/1/2008 by American living in Australia/Japan
Two and a half years ago, my wife’s mother in Australia was diagnosed with terminal cancer. My wife and I moved from Japan to Australia to care for her during the final months of her life. The care she received was excellent throughout.
She was able to go to the hospital whenever she wanted for as long as she wanted, wait times were never longer than what would be expected at a hospital in the US, and ... All her medication was subsidized by the national health care system, and the most we ever had to pay out of pocket was $20AU. In the end, except for the small amount we had to pay for medication, all the care she received cost us nothing. My wife and I … [spent] quality time with her in her last few months rather than worrying that her treatment would bankrupt us.
Last June I had surgery to repair a perforated eardrum and was admitted to the hospital overnight, and I found the care I received to be of the highest quality at no cost to myself.Yes, the tax rate in Australia is higher than in the US, but higher taxes are not crippling the Australian economy. Australians are prosperous and happy, and small businesses thrive there. Thanks largely to generous social programs that help insure a basic standard of living for all Australian citizens, Australia has nowhere near the level of crippling, hopeless poverty that afflicts some parts of the United States. The Australian universal health care system is now so popular that to attempt to eliminate it would be political suicide.
I ... think that if America truly wants to call itself a standard-bearer for freedom and equality in the world it should start by making sure that its own most needy citizens get the health care they desperately need.
Canada 7/21/2009 by two Canadian-American families with great health care — Americans from homestate of CA
Two separate medical condition and health care experiences are shared in one video. The two families refer to themselves as exiles from the United States, unable to return to the United States. They each share that they do not see medical bills. They get care for the rare diseases that a member of each family has. They would like to live in the U.S. but can’t.France 3/4/2009 by an American wife of a French doctor — American from homestate of CT
“ ... health care in France – never been better, and certainly never, ever been less expensive! [As far as single-payer is concerned] ... there is simply no other solution worth considering for the US, and given our tremendous energy and potential for excellence, no reason in the world that [Americans] can’t do it better than anyone else in the world!”
France, then Africa, then Japan 4/9/2009 — American from homestate of KY
In the past 5 years “I have mostly lived in Japan” ... “excellent treatment and follow-up. I am always amazed at the price that I pay when I leave ... so low!” “Ever since my first experience ... in France I have dreamed of a day when the US [would] put such a priority on keeping all its citizens healthy.”Germany 6/18/2008 American — American from homestate of CA
“... almost a dozen eye surgeries [for his mother] ... later became dependent on a nursing staff to come to her apartment ... later had ovarian cancer, was in hospital for three weeks; we did not have to pay any bills for her hospital stay.” He then writes about extensive care that he received over the years and is now back to working full-time and enjoying an active lifestyle.
Japan 4/14/2009 — American from homestate of MN
On 4/9/2009 9 year old daughter was injured; went initially to the emergency room, then to a local clinic the next day and then to the clinic again two days later ... all free.
Spain 3/7/2009 —American
Young American woman was student, worked part time. University arranged for her to get needed medical care. She was monitored for six months and then released. Her bill was zero; she had to pay no more than two Euros for drugs.Go here for the complete testimonials and more of them.
See Our Entire Set of Testimonials
The above stories are simply excerpts.
Learn more here from fellow Americans ...You are invited to read the testimonials of Americans who live and work in free-market countries around the world.
Time to Take Action
to establish the power of the people
It's Time for U.S. Citizens to Take Action
Th information above explains the need for efficiency applied to how we pay for health care in the United States.We can apply efficienciy by implementing national single-payer health care, Improved Medicare for All.Then we'll have the best universal health care in the world.Most U.S. political leaders, including both major political parties, have ignored this need.It's up to us, as individual Americans, to become informed and then decide if we want to sign up to be a Health Care Patriot and participate in our coalition's massive education and communications campagin titled "Million Letters for Health Care".We will have the "power of the people" regarding health care:
— We can be a more powerful force than the opposition's media and lobbyists.
— We can be informed and will grow in our numbers to over 20 million strong in Phase 1.
— We can communicate in a unified, powerful, efficient manner
to Washington D.C. in Phase 2 Communication Events.Feel the power, because we can inform ourselves and each other.
— We can prepare ourselves for the incredibly positive change of universal health care.
— We can cause that incredibly positive change to occur.We can and will get national single-payer health care, Improved Medicare for All ... as long as Americans become Health Care Patriots by signing up (below) and then fulfill the role of a Health Care Patriot.
For example, do whatever you can do among this list:— Inform yourself by a read ... and re-read, as necessary, ... of this web page, and refer to the Index and Answers and Answers TOC. See the links to those web pages at the left of your computer screen. Why? Because we cannot let the media campaigns of the opposition continue to scare us! We must refer to the facts plus the testimonials of fellow Americans and not the scare tactics of the powerful, well-funded opposition.
— Inform others, starting with this web page and the Answers web page.
— Invite others who are informed to sign up.
— Donate once per month or one-time and invite others to donate.Now that the campaign is launched we need tens of thousands of dollars for this massive campaign. But don't worry about the amount. If you can only donate $20 per month ... or ... $2 per month [ or $100 or $10] then please just proceed with whatever amount you can donate.
Sign-up to become a Health Care Patriot
to help get Improved Medicare for All.Sign-up to Stand Up for Single-Payer.
Bookmark with: