As a service to my readers here is my take on the impact of ObamaCare on the future of health care delivery in this country. The following synopsis is based on objective evidence. The impact of cardiology and other chronic illnesses will be profound.
It is my hope the following post serve as a resource that outlines the issues with the new law, the problems Canada and Britain are facing with their current systems, and why ObamaCare should be repealed in its entirety. If you want to jump straight to the socialized health care horror stories, feel free to do so. It is highly recommended reading. But first I would like to start with one from right here in the US, just so the reader is fully aware it not only can happen here, it has happened here (emphasis mine):
The powerful story of Barbara Wagner demonstrates why this discussion is of utmost importance. When Barbara’s lung cancer reappeared during the spring of 2008 her oncologist recommended aggressive treatment with Tarceva, a new chemotherapy. However, Oregon’s state run health plan denied the potentially life altering drug because they did not feel it was “cost-effective.” Instead, the State plan offered to pay for either hospice care or physician-assisted suicide.
In stunned disbelief you may ask, “How can this be? This happens in Europe. I’ve heard stories of Britain’s National Health Service delaying intervention until the patient dies or reports of physician-assisted suicide in the Netherlands. But in America?”
The answer is simple. Oregon state officials controlled the process of healthcare decision-making—not Barbara and her physician. Chemotherapy would cost the state $4,000 every month she remained alive; the drugs for physician-assisted suicide held a one-time expense of less than $100. Barbara’s treatment plan boiled down to accounting. To cover chemotherapy state policy demanded a five percent patient survival rate at five years. As a new drug, Tarceva did not meet this dispassionate criterion. To Oregon, Barbara was no longer a patient; she had become a “negative economic unit.”
In 1994 Barbara’s state established the Oregon Health Plan to give its working poor access to basic healthcare while limiting costs by “prioritizing care.” In 1997 Oregon legalized physician-assisted suicide to offer “death with dignity” to patients who chose to die without further medical treatment. In the end, the State secured the power to ration healthcare in order to control its financial risk, even if that meant replacing a patient’s chance to live with the choice of how to die.
As Canada looks to change its system to allow more privatization due to the sheer cost of universal health coverage or single-payer as it is often called, American is moving in another direction, a direction more closely linked to the British system of public and private insurance that is dubbed the “60 year failure” by many of its victims.
I was born in Canada, and my wife in Great Britain. We see past the airbrushing to the underlying reality because we know relatives exposed to both systems. Some members of her extended family live in Canada. During their last visit to Texas my wife and I learned that the wrong prescription was given to the wife on one occasion, the husband almost died during routine gall bladder surgery when an artery was nicked, and his sister died during an operation because the surgeon refused to continue a treatment for a liver disorder because it was not his specialty – and all of this from a single family.
This is just the tip of the hellish iceberg.
Ronald Regan once said of socialism that it was required in only two places: Heaven, where they don’t need it, and hell where they already have it. Be prepared to be introduced to hell.
Let’s start with what we know of ObamaCare so far, now that we, as Nancy Pelosi put it, passed the bill so we would all have a chance to learn what is in it. Under ObamaCare:
- Emergency Room Volume to Go Up, not Down: …In an article in The Hill, Dallam, a partner at a firm that designs healthcare facilities, notes: “We don’t have the primary care infrastructure in place in America to cover the need. Our clients are looking at and preparing for more emergency department volume, not less.”
- Small Business’s are Hurt, not Helped: One of the great promises of Obamacare was that it would give folks working in small businesses better access to affordable care. Unfortunately, the Obamacare small-business tax credit just doesn’t get the job done, according to the National Federation of Independent Business, the nation’s largest small-business advocacy group. NFIB reports that provisions aimed at expanding small-business-sponsored coverage will have little real impact—though their cost will be all too real.
- Jobs Cut, not Expanded: One of the great promises of Obamacare was that it would give folks working in small businesses better access to affordable care. Unfortunately, the Obamacare small-business tax credit just doesn’t get the job done, according to the National Federation of Independent Business, the nation’s largest small-business advocacy group. NFIB reports that provisions aimed at expanding small-business-sponsored coverage will have little real impact—though their cost will be all too real.
- Harder, not easier, for young people to afford insurance: This week, the White House issued rules for health insurers to extend dependent coverage to “children” up to 26 years old. Beyond keeping the “Big Kids” dependent on Mommy and Daddy, it also directly undercuts the President’s famous campaign promise that American families would see a $2,500 reduction in their annual premiums. Now, we learn that family premiums will rise about 1% in 2012 just from this one provision of the new law. It will cost $3,380 for each dependent in 2011, according to this Associated Press report.
- You can’t keep your insurance if you like it: …CNN reports that AT&T, Verizon, John Deere and others may well drop the health care coverage they now offer their employees. Obamacare makes it much cheaper for these companies to dump their workers into the government-controlled health exchanges and pay a penalty for NOT insuring them….
- Entitlement Crisis worse, not better, as a result of new health care law: …it [ObamaCare] does nothing to reform the overall structure of the Medicare entitlement. While the new law carves out $529 billion in Medicare “savings,” it calls for using those funds—and trillions more—to bankroll even more expansive health care entitlements. According to the National Center for Policy Analysis : “Instead of fixing the health care programs for seniors and those who cannot afford insurance, this law cuts Medicare and adds more people to the failing Medicaid system.” Many seniors enrolled in Medicare Advantage will not be able to keep the plans they like.
- Federal cost will increase, not decease: CMS [Centers for Medicare and Medicaid Services] reports that under new law, overall national health expenditures will increase by $311 billion.
- Expect Longer Waits for Health Care: A recent article from ABC News outlines why Americans can expect longer waits before they see a doctor. One reason is that there just won’t be enough doctors to get the job done. ABC reports that 10 years from now, the United States will short 85,000 primary care and high-demand specialty physicians. Says Dr. Kevin Pho, an internal medicine physician in New Hampshire, “I don’t think we have the primary care capacity to meet the influx of 35 million newly insured.”
- No Promised Coverage for Kids: Major flaws in the gargantuan Obamacare bill started to emerge almost immediately after it was signed into law. One of the most embarrassing: failure to ensure immediate coverage for kids with pre-existing conditions…
- The American people have increased hatred of new law: The repeal message on ObamaCare is picking up steam and the American people have not been convinced by Washington insiders that federally run healthcare is a good idea. Rasmussen reports that the repeal movement is growing. “Support for repeal of the new national health care plan has jumped to its highest level ever. A new Rasmussen Reports national telephone survey finds that 63% of U.S. voters now favor repeal of the plan passed by congressional Democrats and signed into law by President Obama in March.
One can also add to this reduced competition as ObamaCare props up major hospitals while driving physician owned hospitals out of business:
Rob Bluey has a good piece on one of the early casualties of ObamaCare:
Physicians at McBride Orthopedic Hospital had ambitious plans for their Oklahoma City hospital before Obamacare. Two new operating rooms and a four-bed intensive-care unit were part of a multimillion-dollar expansion project that promised to bring competition and more health care choices to the community.
But once President Obama’s signature was dry on the 2,409-page Patient Protection and Affordable Care Act, so, too, was the McBride project. The recently enacted law imposed a series of new federal regulations on physician-owned hospitals, including an immediate ban on expansion.
“We pulled the plug when the law was signed,” McBride Chief Executive MarkGalliart said. “We were ready to break ground. We had everything approved by the state. We had the construction agreement in place. We were going to meet our timeline until the legislation passed.”
The plight of doctor-owned hospitals is one of the areas that was far too neglected during the health care debate. As much as Democrats holler about the skyrocking costs at hospitals, the truth is that for years they have helped to protect the big hospitals from competition from smaller, innovative, hospitals that tend to specialize in one area and can deliver more personalized service.
This one is more personal for me. As many of my readers know I have 25 stents in three major heart arteries, all of them place by Dr. Samuel DeMaio at the Westlake Medical Center in Austin, TX. The service at Westlake is top notch, as are the specialists. When I heard Dr. DeMaio intended on building a new physician owned hospital in Lakeway near Austin, I was quite excited. While the building is still ongoing, major changes to the business model have occurred:
A boutique hospital tucked into the woods of West Lake Hills could be part of a dying breed.
Physician-owned hospitals such as the Hospital at Westlake Medical Center have been targeted by provisions in the wide-ranging health insurance reform legislation that ban new physician-owned hospitals and prohibit existing ones from expanding.
The law is aimed at limiting doctor ownership of hospitals, an arrangement that critics say can lead to conflicts of interest and the siphoning of paying and insured patients, which leaves traditional public and private hospitals to shoulder the burden of indigent care. Safety issues also have been raised over some physician-owned hospitals because of concerns of inadequate emergency room staffing and facilities.
Opponents of the ban have scoffed at those characterizations, but they are forced to live with the new law — at least for now. In Austin, owners and administrators of physician-owned hospitals are coping with the new law in various ways, from changing their business structures to considering selling out to wondering whether to continue at all.
Health care as business venture
Visitors to the Hospital at Westlake Medical Center can easily forget that they are at a place that treats the sick and injured.
On a recent sunny day, employees cleaned an outdoor pool that rippled with swimming koi. Music softly hummed from speakers hidden in the live oaks on the carefully maintained grounds. Inside, visitors traversed floors inlaid with glass from Italy and granite from the Middle East to simulate the Colorado River. African mahogany lined patients’ rooms, and all the tubes and needle-disposal bags were hidden in custom-made cabinets.
The hospital was built to attract patients — or “customers,” as CEO Rip Miller likes to call them.
Now, in the wake of the federal legislation, Miller, the only nondoctor with an ownership position in the hospital, is talking about the possibility of selling his creation to one of the area’s large hospital systems.
With Congress removing the ability to expand the hospital, Miller asked, what’s the point of staying in business?
Growth is the reason any entrepreneur gets into a business, said Miller, who has an ownership position in a hotel in South Africa, a construction company and a cattle ranch in North Dakota.
“I don’t think there will be any physician-owned hospitals in 10 years,” Miller said. “I think it’s sad that the country is going to lose the culture of physician-owned hospitals.”
…When the federal law passed, Lakeway Regional Medical Center was — and remains — under construction.
“Things have changed a little bit because of legislation,” said Samuel DeMaio, a physician and chairman of the board at the Lakeway hospital.
What was going to be a physician-owned hospital will now be something different. The would-be physician-owners switched their equity positions to debt positions.
The facility still will be “run and directed” by doctors, DeMaio said — it just won’t be owned by them.
The doctors still will make a reasonable rate of return, but it will be “nowhere near where it would have been in an equity position,” he said.
Lakeway Regional Medical Center is expected to open in April 2012 and have more than 150 patient rooms and at least 24 emergency room beds, DeMaio said…
…Sandvig said the new law could have a negative effect on the availability of care. She warned that if doctors’ hospitals cannot grow, they might quit taking Medicaid and Medicare patients, whose reimbursement rate isn’t as lucrative as charging insurance companies.
“It limits access to the people that need it the most,” Sandvig said, adding that the result will be “antithetical to the purpose of the bill.”
Sandvig said the association is considering a lawsuit that would seek to lift the ban.
In the meantime, Miller said, he won’t let Congress’ action derail him.
He already has come up with a plan to grow his business portfolio. Miller said he is talking with property owners around the hospital about buying their land.
It’s hard to believe the man who saved my life is being forced out of ownership to remove competition. Welcome to the world of socialism, where it is not steal from the rich to give to the poor, but steal from the productive to give to those unable to produce even something as simple as an original thought.
So what exactly are we in for? Here’s the breakdown:
Daniel Hannan is a young Tory European MP who said of Britain’s National Health Service – which he describes as a “60-year failure” that he “wouldn’t wish on anybody” (emphasis mine):
Of course, the service was not genuinely free: nothing of value is. Free, in this context, was just a synonym for a grant from the Exchequer paid out of general taxation. But for Bevan, using the power of the state to tax money away from the men and women who had earned it had a morality that actually earning money in the first place could never possess. The crucial consideration to him was that, once the NHS was in place, the old shame inherent in accepting public handouts would be abolished, because everyone – bared from the hedonistic pleasure inherent in writing a check to the doctor – would now be a client of the state.
But Bevan’s belief that free service at the point of delivery was a matter not so much of bodily health but of moral purity exercised a continuing and malevolent influence. By turning the NHS into something resembling a religion for milk and water Marxists – which is not an unfair description of Bevan’s political sensibilities – and by crushing the old system beneath the iron but faltering wheels of progress, Bevan at once committed Britain to a single payer system and made criticizing it a form of political heresy. All Gordon Brown did was to take advantage of what appeared to be one of the most prosperous periods in modern British history to remedy the deficiency that had vexed Bevan: the system could never get enough money.
As it turned out, it still can’t: even as Brown blew the doors of the Treasury to pump money into the NHS, private spending on health care in Britain – there is some, in spite of the existence of the NHS – has remained steady at 1.4% of GDP. No amount of public spending appears to be sufficient to meet all needs, or to satiate the public’s demand for better health, a lesson that the U.S. might take usefully to heart. The idea that instituting a British-style system in the U.S. will save money relies on the premise that Americans could be restrained from spending their own money on their own health, and would be willing to accept British levels of government-provided care. Any politician who really believes this is welcome to test the validity of their belief at the ballot box.
Indeed, Britain spends less on health than the U.S. precisely because, like any basically single payer system, the NHS ultimately has to ration what it provides to take account of the public’s unwillingness to pay higher taxes, a reality that accounts for many of the NHS’s failures and horror stories. The NHS’s defenders have the difficult job of protecting it from the reality that Britain is no longer dominated by the old cloth-cap class system that made it so appealing in 1948: the NHS is a top-down system trying to get by in a bottom-up age. But that has not prevented British politicians on all sides from promising to try even harder and attacking the littleness of their opponents’ vision. That is why Brown delights in Hannan’s remarks, which give him the opportunity to demand that even meeting with foreign critics of the NHS be ruled out of bounds by all parties, and to play the old ‘Tory spending cuts’ card. This blissfully ignores the reality that his own Treasury has forecast massive spending cuts after he wins the next election – however unlikely that eventuality now appears – which implies that even a future Labour Prime Minister would have to continue the ceaseless struggle to reduce the cost pressures in the NHS.
…But then the left’s demand for the single-payer system in the U.S. is not about health. It is, as it was for Bevan in 1948, about a vision of social morality, which accounts for the eagerness with which its supporters stigmatize their opponents as unpatriotic and evil. That’s a curious basis, even an unhealthy one, on which to build a health care system, which one might suppose should be judged on its results. But it’s an even unhealthier basis for a political system. There is no surer guarantee of fossilization, and eventual irrelevancy, than mistaking particular policies, which need to change, for immutable principles, which need not. If the British people cannot grasp the difference, Dan Hannan will be the least of their troubles.
So what of the horrors referenced above? The details will stun you (emphasis mine):
According to the Associated Press, the national health provider’s newfound shortfall could “force the government to skimp on dentistry, fertility treatments, and cutting-edge drugs.
The NHS administers both health and social services through health-care “trusts.”
A June report from the new U.K. Care Quality Commission found that care is improving, but “only half of trusts say they meet all current standards” and that “there is significant variation between regions.”
Problems with patient care, meanwhile, have been endemic.
– On June 15, a 69-year-old man from Stockton-on-Tees, Cleveland, in North England, fell victim to an NHS ambulance driver wanting to go home at the end of his shift. Stroke victim Ali Ashgar died in the back of an ambulance when the driver realized his shift had ended and took a detour to clock out and get a replacement driver, the (London) Telegraph newspaper reported. Ashgar’s outraged son told the Telegraph: “If you have a patient in an ambulance you don’t worry about your bloody shift finishing.”
– In January, a 43-year old man, Martin Ryan, died of starvation in an NHS hospital, the Telegraph reported. Ryan was left unable to swallow after suffering a stroke, the paper reported, “but a ‘total breakdown in communication’ meant he was never fitted with a feeding tube.” According to an internal investigation, doctors thought that nurses were feeding Ryan through a tube in his nose. By the time they discovered he was starving – 26 days this was not happening, he was too weak for an operation to insert a tube into his stomach.
“Mr. Ryan, who had Down’s syndrome, died in agony five days later,” the newspaper stated.
The Telegraph added: “Disability charity Mencap said the case was one of several where the NHS ‘completely and unacceptably failed’ patients with learning difficulties through a ‘catalogue of disasters.’”
– In 2007, the now-defunct Commission for Patient and Public Involvement in Health released a study suggesting about 6 percent of patients were forced to treat their own dental problems, with one man using a pair of pliers to remove his own teeth, and several respondents using crazy glue to reaffix crowns.
At the time of the study, Londoner Celestine Bridgeman told the Associated Press: “Trying to find good NHS dentists is like trying to hit the lottery because the service is underfunded.”
– A June 10 report for the consulting firm Tribal suggested “raising the level of self-care” as a solution to the current budget deficit.
The NHS also comes up short on introducing new cancer drugs, receiving a failing grade from many patients, according to Britain’s major papers.
– Kidney cancer patients were enraged in 2005 when they were refused access to the drug Sutent, which could prolong their lives up to two years, because the National Institute for Health and Clinical Excellence, ironically nicknamed “NICE,” did not deem it cost-efficient.
NICE says it “provides guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.”
James Whale, an irreverent British television and radio personality who survived the disease, lashed out at the NHS when it reported its most recent surplus in May.
“They have been pleading poverty throughout the last year, denying sick and dying kinder cancer patients’ drugs, treatment and support,” Whale said in a statement. “(A)ll the while they actually did have the money to save lives and make a difference.”
Sutent has since been made available on a limited basis after public outcry.
– NICE was forced into a similar position in 2006 when Ann Marie Rodgers, then 53, was suffering from breast cancer and was denied Herceptin, a drug that could aggressively attack her tumor.
“They’ve got no right to decide who can have this life-saving drug,” Rodgers told the (London) Daily Mail at the time. “This is not a poor country, after all. I have worked all my life and paid my taxes.”
The group Women Fighting for Herceptin was formed to raise money to fund the drug and held rallies decrying the fact that NHS and private trusts where the drug was not offered.
“It makes me sick to think a lot of women are in my position,” Rodgers told the Daily Mail. (Rodgers died in June, two years after finally winning a court battle forcing the NHS to make the drug available.)
But wait, there’s more:
Crisis in elderly care far worse than feared, report warns, which includes a recommendation to the NHS to provide “a minimum level of service” to the elderly. Coming soon to a health care system near you.
Patients are routinely being treated in kitchens, mop cupboards and corridors because hospitals are so overcrowded, a shocking survey reveals.
Third World conditions are commonplace, with hospitals housing patients for days in storage areas, offices, TV rooms and outpatient clinics.
This disturbing treatment of the sick and vulnerable comes despite a tripling of the NHS budget by Labour over the past decade.
The survey of 900 nurses follows a Daily Mail story telling how Doris McKeown, 80, spent 48 hours in a supply cupboard while waiting for surgery at the Norfolk and Norwich University Hospital.
Many nurses also told how extra beds were often crammed into wards to avoid breaching a Whitehall target on A&E waiting times.
This increased the risk of infection and threatened patients’ privacy and dignity, especially on mixed-sex overflow wards.
Examples of appalling care cited by staff included:
- A woman ‘barely coping’ after a miscarriage being sent to a ward with male patients.
- Children left at ‘high security risk’ and a threat of infection when adults were put on their ward.
- One overflow ward being so crammed a nurse could not reach the emergency buzzer when someone had a heart attack. She had to run into the corridor to yell for help.
- One patient being left in a mop cupboard where there was only room for a chair, not a bed. At another hospital, a kitchen was set aside for two beds.
- A hospital discharging elderly patients before they were ready.
- Another using a ward which had been ‘condemned’ for patient use.
- Up to three patients being crammed into a tiny office cluttered with staff belongings.
- Eighteen patients being stuck on trolleys in the corridor of a medical assessment unit.
One nurse said: ‘The only thought is of “stopping breaches” [of targets]: put patients anywhere as long as the box gets ticked.’
The revelations follow a series of NHS scandals, including the deaths of up to 1,200 people at Stafford Hospital, where targets were found to be largely to blame.
The Nursing Times survey also found that beds were ‘faulty’ and ‘condemned’, fire exits were blocked, toilets were ‘inadequate’, and many patients went without showers and baths.
Maintaining single-sex areas was often impossible because of the sheer numbers of extra patients.
Nurses have to take blood samples in corridors and beds are sometimes placed in isolated corners, meaning nurses cannot see if a patient needs help.
Elderly patients are ‘parked’ in day rooms while waiting to be transferred to another hospital, and left ‘soiled and neglected’, and ‘needing fluids’.
Sometimes spare beds run out – and people have to sleep on chairs or mattresses on the floor.
Nearly half the nurses said patients in non-clinical areas did not have proper access to water, oxygen, suction and a call bell.
Four in ten said they did not have the screening to protect their dignity and privacy.
‘If a patient suddenly had a cardiac arrest, we would not be able to get the crash trolley to them,’ said one nurse at a hospital which squeezed extra beds into wards.
Others said cramming patients into wards put them at risk of cross-infection.
One added: ‘Urine bottles are not emptied, meals are missed as staff are not aware of the patient.’
I can hear it now: “Yes, I’m here to visit mum and was wondering what cupboard I could find her. Right next to Mother Hubbard you say? Tah.”
I already shared a few examples from one family in Canada related to me through my wife. Their problems are not unique. A simple Google of the phrase canada health care horror stories and its variants turn up a number of hard to read examples. Canada faces the exact same issues as Britain and our genius government is going to attempt to duplicate these programs here where instead of 30 million people (Canada) or 60 million people (Great Britain), we have 300 hundred million people – AND – we are going to do it for about 1 trillion dollars over a decade if Obama is to be believed. The reality is that ObamaCare will cost U.S. taxpayers over 6 trillion dollars in the first decade alone. Wow, free health care redefined. How’s that deficit working out for us? The Greeks, Italians, Portuguese, and Spaniards are just loving it right now.
Shall we get started?
- To Avoid Year Long Wait, Canadian Patient Flies to India for Hip Resurfacing
- Patient Wait Times Cost Canada $15 Billion a Year
- Fed Up Canadians Choose Surgery Overseas
- Doctor Advises Patient to Fly to Italy for Cancer Treatment
- Canadian’s Access to Drugs Blocked by Goverment Policy
- Excruciating Wait Times
- Government Health Care Only Looks Good on Film
- Why Ontario Keeps Sending Patients to the US
I could go on and on, but I think the reader gets the picture. Unless ObamaCare is repealed either through the legislative process or state level nullification the fact remains that if it is not repealed we are all, to be quite blunt, screwed. At least Canada is starting to get the picture that something is seriously amiss:
American fans of single-payer health care have long held Canada as an example of success in both providing health care and controlling costs. Canadians have more reason to question both, however, especially the latter. The provinces, which bear a significant portion of those costs, may end some services and curtail others as ballooning costs have exposed the cradle-to-grave system as unsustainable:
Pressured by an aging population and the need to rein in budget deficits, Canada’s provinces are taking tough measures to curb healthcare costs, a trend that could erode the principles of the popular state-funded system.
Ontario, Canada’s most populous province, kicked off a fierce battle with drug companies and pharmacies when it said earlier this year it would halve generic drug prices and eliminate “incentive fees” to generic drug manufacturers.
British Columbia is replacing block grants to hospitals with fee-for-procedure payments and Quebec has a new flat health tax and a proposal for payments on each medical visit — an idea that critics say is an illegal user fee.
And a few provinces are also experimenting with private funding for procedures such as hip, knee and cataract surgery.
It’s likely just a start as the provinces, responsible for delivering healthcare, cope with the demands of a retiring baby-boom generation. Official figures show that senior citizens will make up 25 percent of the population by 2036.
My health-care prejudices crumbled not in the classroom but on the way to one. On a subzero Winnipeg morning in 1997, I cut across the hospital emergency room to shave a few minutes off my frigid commute. Swinging open the door, I stepped into a nightmare: the ER overflowed with elderly people on stretchers, waiting for admission. Some, it turned out, had waited five days. The air stank with sweat and urine. Right then, I began to reconsider everything that I thought I knew about Canadian health care. I soon discovered that the problems went well beyond overcrowded ERs. Patients had to wait for practically any diagnostic test or procedure, such as the man with persistent pain from a hernia operation whom we referred to a pain clinic — with a three-year wait list; or the woman needing a sleep study to diagnose what seemed like sleep apnea, who faced a two-year delay; or the woman with breast cancer who needed to wait four months for radiation therapy, when the standard of care was four weeks.
So there you have it, in a nutshell. This foundation of this system must be torn out from the ground and never be allowed to take root in this country. If you think this is a joke or I am scare-mongering, think again. If your not sick, it sure looks good, but if you or a loved one ever gets seriously ill, just look to Canada and Great Britain to see what type of treatment you can expect under ObamaCare. Kill it. Now. Before it kills you or someone you love.
Filed under: Health Care
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