Answers To Commonly Asked Questions About National Single Payer

John R. Battista, M.D.

President, Connecticut Coalition For Universal Health Care

July 21, 2006

1.      Wouldn’t a national single payer insurance system be socialized medicine?

          A single payer, universal health insurance system would guarantee a right to health care for all citizens of the United States .  In that sense health care, like primary and secondary education, would become socialized.

          However, the health care delivery system would not be socialized.  Single payer is a health care insurance system, not a health care delivery system.  In the single payer system we advocate, the fee for service, private delivery system would remain intact and be expanded by “privatizing” the direct health care services provided by states. 

          The health care system would become socialized under a single payer system only if health care practitioners were paid a fixed salary for their services.  We do not advocate such a system as it is not in accord with American values and would be unacceptable to the majority of health care providers, although it has been successfully utilized by the Veterans Administration and pre-paid group health plans such as Kaiser. 

2.      What would a single payer health insurance system cost relative to our current multi-payer health care insurance system?  Wouldn’t enacting such a system result in a massive tax increase?

          All of the prospective state and national studies on the cost of single payer relative to our current multi-payer system predict savings of about 10%.  The savings predicted by these studies is supported by data from single payer industrialized countries who generally spend less than half of what the United States spends per capita on health care while providing generally comparable outcomes for acute illnesses, and generally superior outcomes for global health care data such as infant mortality, and longevity. Canada, which had similar health care expenses as the United States when it enacted its single payer system over thirty years ago now spends half what the United States does on health care per capita despite having surpassed the United States in terms of overall health care indices.

          In the short run, savings primarily result from decreased administrative expenses (around 50%) and decreased costs of purchasing medications (around 40%).  In the long run, additional savings result from improved access to health care which prevents illness and lowers the costs associated with it through earlier intervention. 

          In addition, there are many other savings under a single payer system that were not considered by prospective studies.  First, as stated above, the initial 10% savings will be increased over time due to preventing illness and early intervention.  Second, a single payer system would reduce health care costs by coordinating and consolidating medical services and medical equipment.  Third, insurance plans which have medical benefits attached to them, such as workman’s compensation insurance and car insurance would cost substantially less under a single payer system because conflicts over the cause of medical injury would no longer have to be adjudicated by legal proceedings.  Finally, a single-payer universal health insurance plan would control costs by controlling the rate of reimbursement for medical services.  Although, it is not the intention of single payer advocates to reduce the income of health care providers, health care providers will experience a substantial (28%) reduction in administrative costs, experience a reduction in malpractice insurance, save time by no longer having to have care pre-approved, and experience an increased demand for their services.  All these factors would allow reimbursement for health care procedures to be decreased while maintaining income.

          While it is true that funding the single payer health care insurance system would significantly raise taxes, the health care costs to the average resident and business would be reduced due to no longer having to pay for health insurance.   

3.      Prospective studies on single payer which show substantial savings under a single payer system are based on showing that the cost to provide the same package of medical services under single payer is less than providing the same package of medical services under our current multi-payer system.  However, wouldn’t demand for health services increase under a single payer system thus decreasing or eliminating the savings predicted by these studies?

          It is true that the prospective single payer studies are based on calculating the cost of delivering current health care services if the current multi-payer insurance system were replaced by a single payer insurance system.  It is also true that demand for medical services would increase under a universal health insurance system, particularly in the short term, as there are many unmet medical needs in our current population, specifically in the area of elective surgeries such as knee replacements, cataract surgery, and dental care.  However, increasing access to outpatient care under a single payer system will decrease the number of hospitalizations and utilization of emergency services, thereby compensating, at least in part, for the cost of increased demand in other areas.

          Most prospective studies suggest savings in the health care system of around 10% under single payer.  We believe that increased demand for health care services may be around 10%, compensated, in part, by the hospitalizations that will be avoided and the decreased utilization of emergency services that will occur as a result of improved access to outpatient care. When Canada enacted its single payer system, demand for health care services increased by much less than 10%.  Thus, we believe a single payer system should be funded at its current level to assure adequate funding.

4.      Who would administer the national single payer health insurance system if it were enacted?  Wouldn’t single payer result in a government run health care system?

          A small minority of single payer advocates suggest single payer insurance be administered by the government.  They site the efficiency of our federal government in administering Medicare, which has administrative expenses of about 3% in comparison to private insurance companies which consume over 15% of health care premiums in marketing, profits, high salaries and managed care operations.  However, there is a deep mistrust in the population of a government run program and profound skepticism that a government system would be efficient, effective, and responsive.  Physician groups in particular are mistrustful of a government run system because they experience Medicare as unnecessarily complex and insufficiently responsive to their needs, although many appreciate the lack of managed care in traditional Medicare.

          For these reasons, we advocate administering a single payer system through a not for profit trust under the control of a board of directors accountable to Congress.  We believe such a board must meaningfully represent each group that has a vested interest in the health insurance system to negotiate solutions to those issues which the administrative body will be called upon to resolve, such as determining fees for services and the breadth of health care services to be covered by insurance.  The six groups that would need to be represented in such a board are health care providers, health care organizations, patient advocates, tax payers, businesses, and government officials.   

          Other single payer advocates support administering a not for profit trust by an appointed board of health care delivery experts, similar to the federal reserve system.  Although this may be an acceptable model, we oppose it because it does not ensure input from groups that have a vested interest in the system and deprives them from selecting their own board members to represent them.

5.      How would a single payer system be financed?

          Four sources of income could be used to pay for the health insurance of a single payer system: existing state and federal programs, excise fees on activities detrimental to health, employer payroll premiums, and family health premiums.

          The state and federal governments would transfer funds that are currently being utilized to pay for Medicare, Medicaid, and CHIPS programs into the system.  Emphasis should be placed on making sure every eligible person is enrolled, thus maximizing state and federal funding for the universal health insurance program.  The increased cost to the states of having more people enrolled in these federally mandated programs would be compensated by no longer having to administer these programs, no longer providing direct services, and the decreased per capita cost of services.

          We support excise fees on activities detrimental to health to the extent that these activities can be shown to increase health care costs.  For example, we recommend that tobacco products be taxed to the extent that funds generated from this tax would equal the health care costs that can be reasonably shown to be attributable to their use.

          Many single payer advocates recommend that employers pay a percent of their payroll to the insurer to partially or fully pay for the cost of health insurance for their employees.  Many advocate for a sliding scale on payroll taxes so that the smallest employers would pay the least, while the largest employers would pay the most, although all agree that the tax on large employers should be less than what they are currently paying on average.  Some single payer advocates suggest relieving businesses from having to pay insurance costs; instead, making these payments a matter of negotiation between employer and employees in lieu of employees paying an income based health care tax.

          Generally, single payer advocates suggest that all families pay a fixed percent of their income to cover health insurance.  However, most single payer advocates believe their should be no cost to families whose income is less than 185% of federal poverty guidelines.  Some advocates argue there should be a cap on family payments because high income families would pay substantially more for this insurance than comparable insurance available through the private sector.  Others, such as our group, disagree, arguing a flat tax on income is just because all families would pay the same percent of their income for health insurance.  Additionally, adjustments would have to be made for people eligible for Medicare and Veteran’s benefits, as these individuals will already have the cost of most of their medical insurance paid for them by the federal government.

          As is readily apparent, this is a complex, critical and potentially contentious aspect of enacting a single payer system.  It reveals the need to obtain input or ensure representation from businesses, organized labor, Medicare advocates, Veterans advocates, health care providers, health care organizations, and taxpayers who would be directly effected by the recommendations of a board to Congress concerning health care funding. 

          However, because a single payer system would be more cost efficient than our current system it should be possible to provide universal health insurance while decreasing the cost for the average family and employer.  When cost estimates have been constructed on a national level, without considering excise taxes on activities detrimental to health, it has been determined that a 2.5% income tax and a 6.5% payroll tax would adequately cover the costs of a universal health insurance system.  Such a revenue system would create substantial savings for the average large corporation and all but the wealthiest families. 

6.       It is often stated that the United States has the best health care system in the world.  Wouldn’t quality of health care decrease under a single payer health insurance system?

          No. The best health care in the world is available in the United States if you can pay for it.  However, the United States does not have the best health care system in the world.  To evaluate the health care system of the United States , the health care indices of American citizens must be compared with the health care indices of the citizens of other industrialized countries.

          Among the 29 industrialized nations, the United States ranks in the poorest third with regard to infant mortality and longevity, the two most accepted criteria utilized to assess health care systems.  This is accounted for by the universal availability of health insurance in other industrialized countries.  It is well known that health insurance increases longevity by encouraging individuals to seek medical attention early in the course of a disease when it is easier to treat and less costly.  Furthermore, many individuals without health insurance, or because of limited financial means, avoid health care visits and treatments, shortening their survival and increasing the cost of treatment.

          When quality of care comparisons are made between the United States and Canada-- the country whose population and culture is most similar to the United States--in terms of survival from cancer, coronary artery disease, kidney failure and a wide variety of other illnesses, Canada is equal to or superior to the United States.  In addition, Canada , which ranked behind the United States in infant mortality and longevity when it passed its single payer system, now surpasses the United States on both these criteria.

          Single payer would improve the quality of care, not just for the poor and uninsured, but for the general population, by replacing the for-profit, managed care portion of our health care delivery system with private, fee-for-service medicine in which health care decisions are made by the health care provider in conjunction with the patient.  For-profit, managed health care has been shown to provide poorer quality care, and to be less satisfying to the public, as per a comprehensive July, 1999 review in the Journal of the America Medical Association by Himmelstein, Woolhandler, Hellander and Wolfe.  

          To summarize, it is expected that a single payer universal health insurance program would increase the quality of care both by minimizing the negative impact of for-profit, managed care and by increasing the health and longevity of the population as a result of providing universal health insurance coverage that would enable access to preventive health care and early intervention in medical illness which is lacking in a substantial portion of our population under our current multipayer-system.

7.      Wouldn’t there be waiting lines, like Canada , if the United States were to pass single payer, universal health insurance? 

          There are substantial waiting lines in Canada for elective surgeries and diagnostic tests.  This has resulted in the emergence of private alternatives to the Canadian Medicare system to address these problems.  Waiting lines in Canada are the direct result of the poor funding of the Canadian system relative to the per capita spending on health care in the United States .  In fact, Canada spends less than half of what is spent per capita on health care in the United States .  As a result, Canada has a much less developed medical infrastructure than most American states and has limited access to the diagnostic and elective surgical aspects of its medical system to constrain costs.  Most American states have a generous supply of health care practitioners, hospitals and diagnostic equipment.  Therefore, in most states, demand for medical care could readily increase without lines.  Furthermore, increased demand for services could be readily accommodated by increasing the number of medical practitioners.  Because per capita spending would continue to be more than twice the per capita spending in Canada there would be no waiting lines in most states.  Put the other way around, Canada would have no waiting lines if its health care system were to be funded at the levels of current American per capita spending.

8.      What problems of our current health care system would be solved or not solved by enacting a national single payer universal health care insurance system?

           It would solve the problem of the uninsured.  This group of predominantly working individuals and their families have both poorer health care and higher health care costs than the insured segment of our population.  Single payer would provide the uninsured comprehensive health insurance which would improve their health and lower health care costs not only for them, but the entire population. 

          It would solve the problem of the underinsured; the 25% of those insured who would be bankrupted by a major medical illness.  Single payer would protect them from medical bankruptcy, the leading cause of bankruptcy in the United States .

          It would solve the problem of moderate-income workers who are locked in unwanted jobs because they would lose their health care benefits if they were to leave their job.  Single payer would allow these workers the freedom to choose their work without losing their health care benefits. 

          It would solve the problems of Medicare recipients who, on average, spend 20% of their disposable income on health care.  Single payer would decrease out-of-pocket expenses for Medicare recipients. 

          It would solve the problem of substandard medical care for the poor through Medicaid because the low reimbursement rates of Medicaid keeps the best health practitioners from participating in it.  It would also solve the problem of access to medical care experienced by many poor families under Medicaid.  By providing the same quality health insurance to all individuals, regardless of income, the quality of medical care and access to care for people currently insured by Medicaid would be greatly improved. 

          It would solve the problem of businesses struggling to provide health insurance benefits for their employees.  Single payer would make health care insurance more affordable to small businesses and decrease the onerous expense of health care insurance experienced by many large corporations.  In addition, single payer would assist all businesses in lowering the cost of workman’s compensation.  Single payer would decrease workman’s compensation expenses by alleviating the need to adjudicate conflicts over whether a medical problem is job related or not, thereby saving time and money. 

          Single payer would resolve the problems of managed care: the breach of patient confidentiality that comes from subjecting physician’s treatment recommendations to insurance company pre-approval; the compromise of patient care that results from health care recommendations being micro-managed to minimize costs; the disruption of the doctor-patient relationship that results from insurance companies having limited provider networks; and the frustration that many patients and health care givers experience in accessing and providing health care through the managed care system.  Single payer would provide free choice of health practitioner, ensure the right of health practitioners and patients to determine the most appropriate health care for them, ensure the continuity and confidentiality of care, and facilitate access to health care.

          A single payer system would not solve the problem of the lack of coordination of medical care or the medical errors which occur in our health care system.  However, it would be relatively easy to coordinate medical care and medical record keeping under a single payer system.  Additionally, by relieving the hospital system of the dire financial pressures it currently faces, it could decrease the number of medical errors that occur under our current system.

9.      Wouldn’t the cost of a single payer system inevitably increase and run into the kind of deficit problems that threaten the Medicare system?

           No.  This definitely would not be the case.  Medicare is a prospective payment insurance system in which taxpayers pay into the system during their working years to obtain medical insurance when they are 65 or disabled.  A single payer system is a balanced budget system in which costs and funding would be adjusted on a year to year basis in order to ensure a balanced budget.

          Although, costs for health care may increase as the population lives longer and new treatments/procedures are discovered, international experience shows the rate of increase will be much less under a single payer system than our current multi-payer system.  

10.  Under a national single payer system, who would decide what medical procedures for a particular individual would be paid for?

           As we envision it, the Board of Directors of a Health Care Insurance Trust would negotiate a benefits package that would be insured subject to Congressional approval.  There are three basic models for carrying out that insurance package for a particular patient with a particular medical need.  In the first model, the licensed health care practitioner in collaboration with the patient decide on the appropriate care to be paid by the insurer.  In the second model, medical care decisions are made by the primary care physician in conjunction with the patient, and specialty services must be certified by the primary care practitioner before they will be covered.  In the third model, the insurer manages health care services. 

           It is clear that the vast majority of health care practitioners dislike the managed care model and would oppose working in an insurance system that micro-managed their decisions.  In addition, such a model would increase the administrative costs of the system in a way that would make it much less cost effective.  For that reason, we strongly believe there should be no managed care in a single payer health care insurance system. 

          Both the totally unmanaged system and the primary care model might be acceptable. Practitioners would definitely prefer the unmanaged model, but the primary care gatekeeper model does have the potential advantage of better coordinating care and potentially constraining health care expenses.  On the other hand, a primary care model would necessitate additional office visits, be somewhat more complex and expensive to administer, and constrain patient choice, thereby making it less appealing to the average person. 

     Overall, we advocate the model in which health care decisions about services covered by the insurance benefit package are made by the health care practitioner in collaboration with the patient. 

11.  What would happen to the insurance workers that would be displaced by a single payer health care system?

           It is true that many people who work for insurance companies or for state governments in health care related jobs would be displaced by a single payer system.  Although some of them could be employed by the new single payer system, inevitably a substantial number would become unemployed.  In that sense, they would bear the cost savings of the new health care system.  For that reason, we believe the single payer system should expend some of its resources to re-train those workers who are unable to find employment after they are displaced.  Because a single payer insurance system will increase demand for health care services a good number of them could be re-trained as health care workers.  

12.  What would be the economic impact of a single payer insurance system for the United States ?

           Overall, the impact would be very positive.  Because the cost of health insurance would be substantially decreased for businesses, American businesses would become much more competitive internationally.  Additionally, because workers would no longer be stuck in jobs they do not want in order to maintain health care benefits, worker productivity should increase.  Furthermore, the cost of insurances which have an health care aspect, such as workman’s compensation and car insurance, would substantially decline further improving the competitive position of American companies or lowering prices. 

13.  Would a single payer system be acceptable to health care practitioners and the general  public?  Who would oppose this system being enacted?

          Health care practitioners are frustrated by the lack of health insurance for a substantial part of the population and by the complexity of obtaining coverage and compensation for medical services they perceive as necessary and appropriate.  Furthermore, they are distressed by their inability to negotiate fees for their services with insurers.  They would support a single payer, universal health insurance system to the extent that such a system did not result in a substantial decrease in their incomes, freed them of pre-approval and administrative hassle, and provided them with an opportunity to negotiate fees for their services.  A single payer system governed by a board in which they were fairly represented would meet all of these requirements.

          The general population is frustrated by the high cost of medical insurance, the complex task of accessing medical care under it, and the problem of the uninsured among us, which they recognize increases the cost of health care for us all.  They would support a single payer, universal health insurance system as long as it did not cost more than the current system and decreased their frustration with accessing care within in.  The majority of Americans support fundamental change in our health care system and support the conversion of our multi-payer system to a Canadian style system.  On the other hand, over 90% of Canadians support their system and would oppose its transformation to an American style system.

          Single payer would be opposed by insurance companies who would lose their health care insurance business and pharmaceutical companies who would have their profits curtailed by negotiating the price of prescription drugs by the single payer agency on behalf of the population.  To some extent it may be opposed by very wealthy families who would experience an increased cost of health insurance under such a system.  It would be opposed by those individuals who do not view health insurance as a right.  Finally, it would be opposed by businesses who currently do not offer health insurance to their employees if they were mandated to pay a percent of their payroll to support the health insurance of their employees.

14.  How would fees for services be determined in a single payer insurance system?

          Ideally, fees would be set by the single payer insurance system in negotiation with representatives of health care practitioners and taxpayers.  This would be a major improvement over our current health care system where fees are set for health care practitioners by insurance companies without representation or by health care practitioners without adequate consideration of patient finances.

15.  Are there legal issues that would need to resolved before a single payer universal health insurance system could be enacted?

          Yes.  A waiver would have to be obtained from the federal government to pay for the medical care of those individuals covered by federal mandates on a lump sum basis.  Such a change would be welcomed by the current federal administration which has proposed this as a solution to the current difficulties with the Medicare and Medicaid systems.

          We do not believe there would be a legal problem with insurance companies under a single payer system.  Such companies would still be free to offer medical insurance, although there would be no reason for citizens to purchase such insurance.  Insurance companies might argue that their ability to do business has been taken from them and sue for losses under the WTO.  This is something on which expert legal opinion should be obtained.

16.  How would a single payer system deal with issues of cost containment, quality assurance, and fraud?

          We envision cost containment, quality assurance and fraud issues to be handled through a Quality Assurance Division of the not for profit trust which would administer the insurance system.  Such a Quality Assurance Division would work with a health practitioner advisory board to determine pragmatic and cost-effective quality standards, which would be used to educate providers on cost containment issues.  The system would thus educate health care practitioners through quality of care standards rather than micro-managing individual cases.

          Quality assurance would be handled in two ways.  First, by investigating complaints from patients about their practitioners or health care organizations.  Second, by investigating those situations in which the pattern of utilization of a particular health care practitioner differs significantly from the patterns expected under the quality of care standards established by the insurer with input from health care practitioners and health care organizations.

          Fraud would be investigated through a system similar to Medicare.  Practitioners whose patterns of care significantly differ from their colleagues in the state would be investigated to determine if the basis for these discrepancies is fraud.  Furthermore, consumers would receive copies of all billing done by their practitioners and be encouraged to report discrepancies between what was billed for and what services their caregiver provided.

 18. Isn’t it inevitable that the proposed health care system would be less efficient because it would stifle the competitive, free market system?

           There is nothing about a single payer system that would stifle competition in health care.  Health care practitioners and health care organizations would still compete with one another for patients.  In fact the system would become more competitive because everyone would be free to see any health care practitioner.  There would be no limitations on practitioner choice as there is under the current health care system: all licensed practitioners would be allowed to participate in the system.  However, as in our current system, there would be little or no competition among practitioners on the basis of cost.

19. Will access to alternative medicine practitioners be covered?

          The visits and treatments recommended by any licensed health care provider in a particular state would be covered.

20. Many other proposals have been made to solve our current health care problems: high deductible insurance in combination with medical savings accounts; increased governmental support for people of limited means to make health insurance more affordable; governmental mandates to either a) demand all citizens obtain health insurance or b) demand businesses provide health insurance for their employees or pay money to the government to allow it to offer affordable health insurance.  What is your opinion about these alternative proposals?

          High deductible, low cost, insurance programs in combination with a medical savings account save money for those individuals eligible for them and save money for companies who currently provide more expensive health insurance for their employees.  However, their overall economic impact is minor as 80% of all medical expenses are accounted for by 20% of the population, mostly in their last year of life.  In addition, it is unclear if patients exercising more discrimination over health care expenditures decreases over all health care costs.  The increased costs of health care associated with lack of insurance and the recent RAND study showing that waving co-pays actually decreases health care expenditures suggest otherwise.  Certainly this approach would do little or nothing for the uninsured population who still would not have the financial means to afford such high-deductible health insurance, and may increase the percentage of underinsured in our country who face medical bankruptcy as a result of major medical illness.

          Additional government subsidies for people of limited means to make health insurance more affordable would be useful in decreasing the number of uninsured but increase government expenses.  In addition, it would not address the main reasons health insurance is so much more expensive in this country than in other industrialized countries:  the high administrative costs associated with private insurance, and the high cost of prescription medications as a result of the inability of individuals and many insurance programs, such as traditional Medicare, from negotiating the price of  prescription medications.

          Pay or play mandates on businesses would decrease the number of uninsured and allow governments to provide lower cost health insurance for the population.  However, it would do nothing to decrease the administrative overhead and inability to negotiate the price of prescription drugs which are the main reasons health care insurance costs are so high in the United States relative to other industrialized countries.

          Direct mandates on the population to purchase health insurance, as was recently passed in Massachusetts ,  would presumably decrease the number of uninsured by criminalizing the lack of health insurance.  However, this would place a further economic burden on financially strapped Americans and do little or nothing to lower health insurance costs.

          On the other hand, we would support the federal government mandating universal health care insurance to the states and allowing each state to find its own means to provide universal health care insurance.  We believe that kind of experiment would show single payer to be the most effective and efficient universal health insurance system.

21. Wouldn’t it be unethical and undemocratic to force people to pay taxes for health insurance they do not want, particularly since people who are wealthy and many young families would have to pay more for health insurance under a single payer system than they would pay under our current multi-payer system?

         This question equates democracy and ethics with free choice and perceives paying taxes for a system which a particular individual does not support to be undemocratic and unethical.  From this perspective, taxes to provide funds for education, welfare,  and environmental protection might all be considered undemocratic and unethical.  This question implies the only good government is one that allows its citizens to do what they want and does not interfere with their acting in accord with their own perceived self interest.

         However, we do not believe democracy refers to freedom from taxation for public expenses one does not support, but rather, refers to the right to meaningfully influence and participate in government.  Single payer, as we advocate it, is particularly democratic because it returns the right of influence and participation to the very individuals and groups which are directly affected by health care insurance.  Under our current system, decisions about health insurance are commonly made by politicians, federal and state health care administrators, and executives of corporations without the meaningful participation of health care providers, health care recipients or taxpayers.  Single payer, as we envision it, would allow these groups to be fairly represented on a board and to be empowered to make decisions about costs and benefits, subject to legislative approval.  Such a single payer system would expand the democratic control of our current health care system and would constitute an improvement over those single payer systems which are administered by limited participation government systems.

          We consider single payer health insurance to be ethical because it makes access to health care a right.  Under our current health care system, access to health care is limited by ability to pay.  The poor receive second class health care under the state Medicaid system, while low paid hourly workers are most likely to forgo health care because of cost, and pay a much higher percent of their income for it.  Moreover, because of the relationship between ethnicity and class, African Americans and Hispanic Americans are most likely to be without health insurance, have poorer health and die younger.  Additionally, for the ill, health insurance cost are increased or fail to cover preexisting conditions.  We consider this financially based health care system to be immoral and unjust because it results in the premature death of the  poor, near poor, ill, and people of color.  Furthermore, we believe a single payer system to be financially just because all families above the federal poverty guideline will pay the same percent of their income for health insurance.  Additionally, the common good is served by single payer through significantly decreasing the cost of health insurance for the vast of the population and significantly improving the health and financial security of the population as a whole.

22.    Would this health insurance be portable?

Yes, the insurance would be good for any participating health care practitioner or hospital in the United States .  We certainly would support the insurance being able to be used internationally.

Contact Information:

John Battista, M.D., 88 Cherniske Road , New Milford , CT 06776

Email: riverbend2@earthlink.net  

Phone: 860-354-1822

Connecticut Coalition for Universal Health Care Website: http://cthealth.server101.com