The Republican TV ads for November must already be filmed and ready to go. Republicans running for state offices have clearly decided to jump on the bandwagon of opposition to the national health care bill.

And so Republicans in the Legislature — led by gubernatorial candidate, Tom Emmer — walked away from $1.4 billion in health care investments that would have immediately shored up struggling hospitals and clinics and held down your health care premiums. This is cynical politics at its worst and Minnesotans should be outraged.

Here?s the background: Minnesota currently pays the cost of health care for about 82,000 of the poorest, most vulnerable Minnesotans without children using only state tax dollars. But this year, we are being given the opportunity to immediately move those individuals to Medicaid, which means that the federal government would pick up half of the cost of their health care. Taking advantage of the offer would be incredibly beneficial for Minnesota.

Indeed, the deal is so good for Minnesota that Gov. Tim Pawlenty (no fan of federal health care reform) initially offered to include the Medicaid option as

part of the final state budget agreement — until Republican legislators raised such a political ruckus that the governor retreated.

So what does the Republican?s decision to kill the opportunity mean?

First, thousands of health care jobs in Minnesota will be lost at a time when we can ill-afford more unemployment. Local hospitals and clinics will miss out

on dramatically improved reimbursement rates and will suffer millions of dollars in losses instead. And every one of us with private health insurance will experience higher premium increases in the future to make up for those losses.

Moreover, by refusing the new Medicaid option, a cash-strapped state of Minnesota will miss the chance to draw down $1.4 billion in federal funds, money that will now go to other states to help balance their state budgets. Passing up the federal help makes little sense for Minnesota which today only gets back about 76 cents for every federal tax dollar paid to Washington, D.C.

Moreover, we could draw down the $1.4 billion with an investment of $190 million state dollars. It boggles my mind that Republicans, who seemingly pride themselves on their business acumen, would have passed on the opportunity to get back $7.45 for every dollar invested.

But that?s not the worst of it. The same Republicans in the Minnesota House who vehemently oppose the Medicaid option today actually offered and supported an essentially identical proposal to move those 82,000 Minnesotans into Medicaid just one year ago!

So why did the Republican legislators flip-flop and reject the chance to preserve good jobs, hold your health care premiums down and get back some hard-earned federal tax dollars to Minnesota?

The answer is obvious: Electoral politics. The Republicans, from Tom Emmer on down, want to scare the people of Minnesota with the specter of “Obamacare” to gain votes in November.

Don?t buy into the fear-mongering. The Medicaid option is not government take-over of health care. It is simply a fuller utilization of a health care program that began in 1965 and is largely administered by private health insurance companies.

In other words, when a Republican legislator or candidate says he opposes “government take-over of health care”, what he?s really saying is that he wants to get rid of a program that already provides coverage for more than 500,000 Minnesotans each month; more than half of them are children and families, the remaining are seniors and people who have disabilities.

So next time you see Tom Emmer or a Republican legislative candidate, ask him why he doesn?t want Minnesota to get more of your hard-earned federal tax dollars back. Ask him why Republican legislators were overwhelmingly for the Medicaid option before they were against it. And ask him why he is unwilling to stand up for Minnesota hospitals and clinics and fight to preserve Minnesota jobs. And when you go to the polls in November, remember the answers.

Dems move to override Pawlenty’s GAMC veto

Paul Thissen earned the highest rating of any candidate for governor in either political party on the Legislative Report Card on Racial Equity.  Thissen was the second-highest scoring legislator, overall.

The Organizing Apprenticeship Project, a Minnesota non-profit that advocates for racial equity, compiled the Report Card. Thissen was named a “champion for racial equity” because of his efforts to advocate for racial equity in the 2009 legislative session.

“Last session, because of the leadership of Paul Thissen, Minnesota made progress toward racial justice.  Progress included requiring hiring equity for green jobs and advancing parity in the criminal justice system,” said Jermaine Toney of Organizing Apprenticeship Project. “Unfortunately, Governor Tim Pawlenty’s unilateral cuts to programs providing critical support for communities of color and low-income families undermined many of the good legislative accomplishments in the 2009 session.”

Thissen was thrilled with the rating, adding, “Minnesota is a changing state.  We are more diverse, growing older, and competing in a global economy.  As Legislators and leaders, we need to be vigilant about the impact that our decisions have on diverse Minnesota communities.  It is rewarding to have that vigilance recognized by advocates for racial equity.”

For a complete copy of the 2009 Minnesota Legislative Report Card on Race Equity, please go to OAP’s website at www.oaproject.org

“Unless there is a broader discussion on who we want to be as a people,” Thissen said the budget and related issues won’t be resolved for the long term.

While he agrees with Republican Gov. Tim Pawlenty’s statements that health care costs are increasing at an unsustainable rate, Thissen disagrees with Pawlenty’s approach.

Recent cuts in General Assistance Medical Care (GAMC) mean more people will be without insurance, because the cuts in the long run mean more expensive visits to emergency rooms, Thissen said.

The cuts also mean an increase in those with mental illnesses who will be without insurance, he said. That will also be more of a long-term cost to the state. At the least, the state must make sure those with mental health issues have insurance coverage for their medications, Thissen said.

“The dominant idea that the best way to succeed is for everybody to make it on their own, (needs to change),” Thissen said.

Minnesotans must consider the obligations they have to each other and then, talk more broadly about solutions and priorities, Thissen said.

To read the rest of the article, click here.

“I want to be clear, the decision to drop health care for over 30,000 Minnesotans was immoral and unacceptable to the people of Minnesota.” Representative Thissen said during visits in Bemidji, Brainerd, and Detroit Lakes. Stops at hospitals in Cloquet, Cambridge and the Twin Cities will continue through this week.

To read more about Paul’s visits, please click on the links below.

Bemidji Pioneer: Panel to hear effect of state GAMC cuts to NCHS

Bemidji Pioneer: Health care cuts increases ER visits

Brainerd Dispatch: Health care officials point to pain from Pawlenty budget cuts

Detroit Lakes Tribune: Legislators tackle health care in visit

MPR: DFLers seek health care options in wake of governor’s cuts

Politics in Minnesota:HCMC stands to lose up to $109 million with GAMC elimination

By Tim Nelson, Minnesota Public Radio, July 3, 2009

Minneapolis — Gov. Tim Pawlenty’s plan to balance Minnesota’s budget is getting some of its stiffest resistance from health care providers.

The unallotment of millions of dollars in health care spending for the poor has them worried about tens of thousands of Minnesotans that may have no more medical coverage next spring.

Democratic lawmakers have been traveling the state this week, trying to come up with another plan for those who are cut off.

Minnesota’s financial crisis may hit hardest in downtown Minneapolis, at the sprawling Hennepin County Medical Center. It’s the flagship of a public health system that gets gets more more than 300,000 clinic visits alone every year.

Cuts to General Assistance Medical Care, or GMAC, could cost HCMC $43 million over the next two years. The money pays for care for people who make eight thousand dollars a year or less.

Former Minneapolis mayor and hospital board member Sharon Sayles Belton laid out for lawmakers what that may mean.

“We will have to reduce or eliminate the services that are what we call the worst financial providers,” she said. “This could include things like our primary care clinic, our specialty services for problems like diabetes, our dental services and some of the components of our mental health service continuum.”

It’s a story that lawmakers have been hearing all over the state.

But they’re offering little hope to health care providers that the cuts will be averted.

State Sen. Linda Berglin, DFL-Minneapolis, pointed out that the cuts are set to take effect next March, just three weeks after the Legislature reconvenes for its 2010 session. She told dozens of people at the House Health and Humans Services Policy and Oversight Committee that there simply may not be enough time.

“I have no idea. If I had a great master plan, in my hip pocket, I’d whip it out and say, oh, look, this isn’t so hard,” she said.

She urged her fellow lawmakers and the health and state at HCMC to come up with a list of where else in the state they could find $400 million to pay for health care for the poor.

But officials are eyeing ideas, too, and hinted at some of them at today’s hearing.

Hennepin County Board Chairman Mike Opat said that the county’s hospital won’t turn the needy away, but property tax payers may have to pick up more of the burden for their care.

Rep. Julie Bunn, DFL-Lake Elmo, suggested that as many as one-third of Minnesotans in their 20s might be eligible for cheap insurance for catastrophic care they could buy in the private market for less than $1,000 a year.

Committee chair Rep. Paul Thissen, D-Minneapolis, said there may be other programs, like housing or social services, that could avert some of the need for health care among the poor.

He also offered some other proposals, like paring back the overall benefit levels offered to the poor and getting more people signed up for Supplemental Security Income, a federal program for the disabled and elderly.

“And you know the governor proposed putting this uncompensated care, reducing funding significantly but putting an uncompensated care pool in place so that the money would not go toward insurance, and getting insurance so the individuals and just having a pool of money that would support places like HCMC or community clinics,” Thissen said.

“We’ve kind of gotten mixed reviews to that kind of thought, because there is a benefit to getting people insured once they leave the hospital doors.”

State and health officials have eight months to come up with a plan B. The existing money officially runs out Feb. 28.

By Brad Swenson, Bemidji Pioneer, July 3, 2009

State cuts to health care for Minnesota’s poorest adults means a 28-year-old diabetic may go without insulin, or a 63-year-old diabetic alcoholic with cancer goes without treatment.

“You need to put a face to who this is going to impact,” Margaret Demers, North Country Regional Hospital lead social worker, told a Minnesota House panel Thursday morning about the effect of eliminating the General Assistance Medical Care program.

The 28-year-old, she said, is on two different insulins which he can’t afford without GAMC coverage. Not taking insulin will lead to more serious medical problems such as organ failure, foot wounds, amputations, and leading to losing the ability to work.

The 63-year-old is short of qualifying for Medicare. “In our area, we have a significant population of chemically dependent patients who fall into the GAMC category,” Demers said. “They struggle with life, their addiction and serious health problems. By its nature, chemical dependency affects their ability to function normally and as their illnesses progress, so do their medical problems.”

Gov. Tim Pawlenty, as part of an effort to bridge a $3 billion budget gap between the DFL-controlled Legislature’s spending bills and expected revenues for the biennium that started Wednesday, line-item vetoed funding for the GAMC program.

The program, which provides health care coverage for the state’s most destitute adults, would see funding cut as of March 1 and into the second year of the biennium. Pawlenty excised about $400 million, a figure that will be $888 million in the next biennium if it is not restored.

The House Health and Human Services Policy and Oversight Committee is traveling northern Minnesota to hear from local hospitals about the affect of losing GAMC, and was in Bemidji on Thursday.

Committee Chairman Rep. Paul Thissen, DFL-Minneapolis, and Rep. Erin Murphy, DFL-St. Paul, and panel staff met with about 25 local medical and social services officials.

Demers outlined six cases of real people on GAMC. “The person may choose to not even seek treatment or not even try because they can’t pay for it. We see that a lot with populations that don’t have coverage. They wait until its turned into a very, very huge medical problem. They don’t come in for prevention or day-to-day management.”

A survey of 10 percent of about 650 GAMC enrollees served by North Country Regional Hospital shows an average age of mid-30s, from 21 to 63, said Jim Hanko, president and CEO of the parent North Country Health Services.

Of the sample, 63 percent were self-designated as American Indians who live in Bemidji or on an area reservation. Seventy-two percent were self-designated as unemployed.

“The majority of the services — 60 percent — were provided in the emergency department,” Hanko said. “And 20 percent were in the imaging department, which is an expensive modality.”

Under a fee for service program, 652 individuals had 1,033 GAMC accounts last year, Hanko said, with gross charges of $3.2 million. State reimbursements were $1.1 million while the cost to provide services was $1.7 million.

And, under the state Pre-Paid Medical Assistance Program, only 55 percent of costs is reimbursed, he said.

“We have an estimate from the state that the total impact for GAMC in our particular locality is about $4.8 million to $4.9 million,” Hanko said. “That includes clinic services received by people at MeritCare and other clinics and includes the emergency department and any in-patient services.”

That amount will become the uncompensated care if all the GAMC patients became patients at NCRH, mostly likely through the emergency department, he said. The emergency room then becomes the safety net for all who can’t afford medical care.

Thissen said the Legislature’s focus will be on the “bigger health care reform that we need to do in this state. … We really need to focus on how we’re going to help this population — folks who are going to be with us regardless whether we’re paying for them or not.”

Murphy is floating around some ideas that may help, she said.

“A lot of them are poor because they’re sick,” she said of GAMC patients. “We know they’re poor because the income standards are so low. … A lot of them are sick and probably not able to work.”

Legislators need to understand the population in order to find solutions, Murphy said, listing off pretty sick, some mentally ill, suffering from chemical dependency, chronic diseases.

“A lot of states are looking at care coordination,” she said. “We keep hearing from hospitals that this population looks at the hospital as their primary care source, to come here to the emergency room because that’s what they know. Is it possible for us to figure out how to deliver care in an out-patient way where the patient is, get them healthier, keep them healthier so they’re not coming to the hospital in their most chronic state, and then we’re incurring these large costs.”

The benefits of coordinated care is savings to the system, delivery of better care, and allowing a better life for the GAMC population, she said. “To do it means we’ll have to work across the system – the health care system and the social services system … to do that kind of intensive coordination.”

It was suggested that the population could be served by more urgent care or “minute clinics,” but there is a lack of primary care providers. It’s tough to recruit new doctors to Bemidji, as rural salaries are lower and on-call hours greater than in the metro area, said NCRH Dr. Robert Rutka.

There were discussions of starting a “minute clinic” but there aren’t enough primary care physicians to staff it, he said.

State changes in credentialing are needed to allow mid-level practitioners to perform some duties now delegated to physicians or physician assistants, said Bob Verchota, NCHS vice president of human resources and ancillary services.

“From a human resources perspective, there’s one thing you could do,” he said, “and that is to support some changes in the licensure requirements through either the credentialing, certifying licensure, etc., to increase the capacity.

“We don’t have the capacity up here from an access standpoint to even get people in if we wanted to,” Verchota added. “We’re sending people … to Park Rapids and Deer River for primary care.”

Some positions are fully capable of providing primary care, such as in lab, rehab or imaging, and in mid-level area alternative to physicians, he said. The problem affects all who seek medical care, not just GAMC patients, he added.

“No supply, the price goes up,” Verchota said.

“It doesn’t make sense to pay lower reimbursement rates to rural communities that are having the hardest time attracting doctors,” said Sen. Mary Olson, DFL-Bemidji.

“We’re actually seeing an outflow of nurse practitioners,” Rutka said. Another problem is while MeritCare has an urgent care office, it closes at 5 p.m., with center referring patients to the hospital emergency room after about 3:30 or 4 p.m.

?We’ve had a net outflow of nine primary care providers in this community in the last three years,” Rutka said. “I, as a family doctor, can probably take care of 92 percent of the things that come through my door.”

Another problem, participants said, with the high percentage of American Indians on GAMC, U.S. Indian Health Service is not always paying for services.

Georgia Downwind of Beltrami County Human Services at Red Lake, said IHS once paid for most services, but the number of those seeking services has grown while money to pay for services hasn’t, forcing partial or no payment.

And, if an Indian who lives on the reservation gets a heart attack while in Bemidji, HIS won’t pay for those services, she said.

“The misperception is that Indian people in this area in the treaties that were signed 100-plus years ago the federal government guaranteed health care services to them,” said Rep. John Persell, DFL-Bemidji. “That’s not being provided, obviously.”

It’s a shortcoming of the federal government, he said. “Indian people believe, and they know because it’s written on paper, we are guaranteeing health care services. That adds to the overall complexity of the situation.”

Indian people have to apply for some other medical service and get denied before using HIS, which Persell said “befuddles” him.

Participants also said transportation was a problem, as many poor adults have no means to seek medical care if they live outside of Bemidji. And, some are homeless and the system can’t find them after they’ve sought initial care.

“In many ways it isn’t a problem of having people finding people, it’s having them stay found,” said John Pugleasa of Beltrami County Health and Human Services. Continuity of care is hard, he added. “Having this population stay found, leading to any kind of continuity, is a real challenge.”

That could be helped with more affordable housing and transitional housing, he said.

By Brad Swenson, Bemidji Pioneer, July 3, 2009

Rep. Paul Thissen, center, talks to DFLers Alan Brew, left, and Jim Heltzer, Thursday morning at the Cabin Coffee House. The Minneapolis Democrat is seeking the party’s endorsement for governor in 2010, and met with local DFLers to solicit their support.

Minnesota needs to go back to its roots of being compassionate to those less fortunate, says Rep. Paul Thissen, who is seeking the Democratic endorsement for governor in 2010.

The direction of government under Gov. Tim Pawlenty for a limited role for state government and for individuals fending for themselves is wrong, Thissen said Thursday in an interview.

“One of the things we haven’t had in this state for too long is a conversation about who we are as Minnesotans and as a people,” the fourth-term Democrat from Minneapolis said. “This next election really needs to be about that; it’s time we do that. We’ve been going down a direction for too long that’s focused on this notion that we’ll all be better off if we’re able to take care of ourselves.”

Thissen was in Bemidji to hold a House Health and Human Services Policy and Oversight Committee meeting into the local effects of Pawlenty’s line-item veto of $400 million to the General Assistance Medical Care program that provides health coverage to the state’s most destitute adults.

Earlier Thursday, Thissen met with about a dozen Beltrami County DFLers to solicit their support for his gubernatorial bid.

“We need to come back to what I think has always made Minnesota successful, which is the idea that we actually do owe obligations to one another, and we have to take responsibility to fulfill those obligations,” he said.

“The GAMC cuts is one primary example,” Thissen said. “I’m hearing from people in greater Minnesota who think that decision of not being willing to take care of our most vulnerable citizens crossed a moral line.”

The economy is sour, but Minnesota also faces challenges of an aging population, environmental concerns, “and we need to start acting now to change the way we’re operating and to be real serious about the solutions,” he said. “We haven’t worried about the consequences.”

Also, he said, the state needs to send more decision-making to local governments.

“It’s become very clear to me that this is a big state and a very diverse state, and one-size-fits-all answers from St. Paul won’t work,” Thissen said. “A lot of the policy work I’ve done over the last year and a half has really been focused on how can we set standards at the state but let local people have a lot more control over how they actually achieve what we all want to achieve.”

Thissen this session carried the Association of Minnesota Counties’ bill to allow the state to set objectives and let counties decide how to achieve them with the state money provided.

“I think it’s really exciting possibility,” he said. “The challenge is that it changes the way the state has to think about it, and we ran into some barriers from that perspective. Folks at the state feel threatened by this new way of thinking. But that’s exactly the direction we ought to go.”

Thissen realizes that the state faces an even larger state deficit in two years, and has plans to close that gap.

“We do need to rethink our tax system” he said, adding that all DFL gubernatorial candidates will offer that idea. “We need to bring more fairness back, we need to bring more revenues into the system. I’m very comfortable talking about that and in making that case.”

Also, over the next five to six years, Minnesota needs to get its health care costs under control. “That is what is eating up our state budget.”

The increasing trend line for health care costs is almost identical to the declining state investment in higher education, he said.

“If we can get health care costs under control, not by what the governor did which is just throwing people off because we’re all paying for it anyhow, but by doing things smarter … that is what is going to save us over the long term”

Savings can also come in long-term care by keeping people in their communities and supporting informal caregivers through tax credits.

“If we can think about not just increasing revenues or cut taxes or cut services, but how can we do things smarter to save money over the next five years, that’s going to be a big part of the answer,” he said.

Some estimates put the next deficit at $7 billion.

“Part of it (closing that gap_ is jumpstarting the economy,” Thissen said. “We can grow some of this out of that. … If we look out over four years, part of it comes back to how we budget as we need to get back to four-year budgeting.”

The budget should include state and local budgets as well, he said, “so we get a picture of our whole public services from a financial budgeting perspective.”

Thissen said Pawlenty, who isn’t seeking re-election, “has left us in a very serious problem. … We did the shift in education of nearly $2 billion this year and we can’t shift any more to the next biennium. The next governor’s going to have a serious problem.

“That’s why it’s really important not to make this election just about health care or taxes or a green economy, but we have to actually make it a discussion of what do we really want the state to look like in five years,” he said. “And what are our values as Minnesotans. Who are we, because if we have that kind of conversation, not only is it good for the politics but it also lets us govern more effectively.”

He says more money needs to go to Local Government Aid to cities, something Pawlenty has cut with each of his budgets and subject to unallotment as of Wednesday.

“They need that support both from a property tax standpoint and a services perspective,” Thissen said, “and from a fairness standpoint across the state. … Another thing just as important as the money is restoring the trust relationship between local governments and the state, which has really been frayed and destroyed.”

An expert in health care policy, Thissen said he would take that reform-minded agenda to other state areas, such as education.

“Health care is the thing I’m really passionate about,” Thissen said. “But that’s not all this campaign is about, and I don’t think it can be.”

He wants to narrow the achievement gap in K-12 between families that are better off and families that are not. He also wants to narrow the gap between districts, bringing equality in areas such as transportation funding.

“Different kids learn very differently, “ he said. “We haven’t done as good a job within our public school systems of providing those different types of learning environments so that different kids can succeed.”

That needs to be the focus more so than testing and outcomes, he said.

Right now, Thissen is meeting with Democrats across the state in small groups, hoping to sway potential DFL delegates to support his endorsement among a crowd of potential and declared Democratic candidates.

An attorney, Thissen is a Harvard graduate. He and his wife have three children.

By Mike O’Rourke, Brainerd Dispatch, July 3, 2009

Area health officials told state lawmakers Thursday how their institutions will be affected by the March 1 elimination of a state medical assistance program for low-income patients without private insurance.

The General Assistance Medical Care program was among the unallotment cuts Gov. Tim Pawlenty made in order to balance the budget after he and lawmakers failed to reach agreement.

The discussion Thursday took place before members of the Minnesota House Health Care and Human Services Policy and Oversight Committee at St. Joseph’s Hospital in Brainerd.

Dr. David Boran, chief medical officer of the Brainerd Lakes Health System, said St. Joseph’s Medical Center cared for 530 GAMC patients this year. Sixty-two percent were seen in the Emergency Department and 20 percent of the 530 patients were admitted to the hospital. He said the gross charges for these patients exceeded $2.8 million. After partial reimbursements are made by the state the hospital costs are $1,093,259, resulting in subsidy of $420,00 to care for these patients.

he GAMC patients, Boran said, are primarily very low-income adults between the ages of 21-64, without children. They often suffer from chronic health problems such as diabetes mellitus, AIDS, heart disease, chronic mental illness or chemical dependency.

Boran noted that as a result of the governor’s veto $18 million in federal revenue in Fiscal Year 2011 will be lost across the state. This year, he said, St. Joseph’s Medical Center will receive $650,000 in Medicare payments for providing a “Disproportionate Share” of care to the poor.

“This plan is penny-wise and pound-foolish,” he said of the veto that will also result in the loss of federal matching funds.

“Minnesotans who pay federal income taxes will, in effect, be subsidizing the Medicaid programs in all those other states that do not cut their Medicaid funding,” he said.

He said the cost shifting that’s part of the health care system – charging those with private insurance more to underwrite the cost of government programs – is a hidden tax.

“This cannot go on,” he said. “Employers in Brainerd and elsewhere are stretched to the limit,” he said. Some can no longer afford to provide health insurance for their own employees, let alone underwrite the cost for others. Brainerd Lakes Health is unable to underwrite additional costs.”

Jani Wiebolt, president of St. Joseph’s Medical Center, said the hospital has implemented a wage freeze, a hiring freeze and has had workforce reductions. She said St. Joseph’s average daily census is 70 patients and noted that there are four hospitals within a 35-mile radius.

Susan Beck, Crow Wing County Community Services director, said the budget cuts would unravel the current health system and force more people to the emergency rooms for health care.

“We’re very reliant on the services of St. Joe’s,” she said. “Without St. Joe’s we lose a huge piece of the mental health puzzle.”

While Beck said she didn’t have a simple solution she told the panel care coordination would be a part of the answer. The needs of GAMC patients often include housing, employment, mental health and medical, she said.

Rep. John Ward, DFL-Brainerd, discussed the good work being done by the Region 5 Adult Mental Health Initiative.

Wiebolt said the hospital has not planned another round of layoffs. She said whatever cuts might come would likely be in the supervisory and support areas rather than “care at the bed side.”

Rep. Erin Murphy, DFL-St. Paul, said “If we don’t solve this problem hospitals are going to take a financial hit.”

Rep. Paul Thissen, DFL-Minneapolis, said an integration of services that would provide ongoing support in such areas as housing, might be part of the solution. Before March, he said after the meeting, he hoped that a different model of GAMC can be structured with an existing revenue source or reform proposals can be initiated that might lead to refunding of the program.

“It’s clear … just eliminating health care coverage is not the way to get there,” he said during the meeting.

Other lawmakers who attended the committee meeting were Rep. Al Doty, DFL-Royalton, Rep. Karla Bigham, DFL-Cottage Grove, Rep. Tom Huntley, DFL-Duluth.