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Is the Senate health-care reform bill still worth passing?


"Insurance companies win," Markos Moulitsas tweeted last night. "Time to kill this monstrosity coming out of the Senate."

This was, for progressives, a frustrating vote. But the flip side of it being morally unconscionable for Joe Lieberman to put the bill at risk over something as small as Medicare buy-in for 3-or-so million people is that the absence of Medicare buy-in -- and of the weak public plan -- is not reason enough to oppose the bill, either.

The core of this legislation is as it always was: $900 billion, give or take, so people who can't afford health-care insurance suddenly can. Insurance regulations paired with the individual mandate, so insurers can't discriminate against the sick and the healthy can't make insurance unaffordable by hanging back until the moment they need medical care. The construction of health insurance exchanges so the people currently left out of the employer-based market are better served, and the many who will join them as the employer system continues to erode will have somewhere to go.

That's all policy. And as I spent yesterday arguing, it has a tendency to overshadow the lives in the balance. You can choose your estimate. The Institute of Medicine's methodology says 22,000 people died in 2006 because they didn't have health-care coverage. A recent Harvard study found the number nearer to 45,000. Since we talk about the costs of health-care reform over a 10-year period, may as well talk about the lives saved that way, too. And we're looking, easily, at more than a hundred thousand lives, to say nothing of the people who will be spared bankruptcy, chronic pain, unnecessary impairment, unnecessary caretaking, bereavement, loss of wages, painful surgeries, and so on.

A lot of progressives woke up this morning feeling like they lost. They didn't. The public option and its compromised iterations were a battle that came to seem like a war. But they weren't the war. The bill itself was. When liberals talked about the dream of universal health-care insurance 10, 20 and 30 years ago, they talked about the plight of the uninsured, not the necessity of a limited public option in competition with private insurers.

"This is a good bill," Sen. Sherrod Brown said on Countdown last night. "Not a great bill, but a good bill." That's about right. But the other piece to remember is that more than it's a good bill, it's a good start. With $900 billion in subsidies already in place, it's easier to add another hundred billion later, if we need it, than it would be to pass $1 trillion in subsidies in 2011. With the exchanges built and private insurers unable to hold down costs, it's easier to argue for adding a strong public option to the market than it was before we'd tried regulation and a new competitive structure. With 95 percent of the country covered, it's easier to go the final 5 percent. And with a health-care reform bill actually passed, it's easier to convince legislators that passing such bills is possible.

On its own terms, the bill is the most important social policy achievement since the Great Society. It will save a lot of lives and prevent a lot of suffering. But moving forward, it also makes future improvements and expansions easier. A lot of the hard work of health-care reform -- in particular, the money for subsidies -- will finish this year. If reformers want to come back for the public option or more subsidies in a future year, they won't be doing it atop a $900 billion price tag that's being battered by tea parties and industry and everyone else. This bill doesn't have all the good stuff it should have, but reformers can stand atop what good stuff it does have and focus their energies on what good stuff is left to achieve.

Photo credit: AP Photo/Haraz N. Ghanbari.

By Ezra Klein  |  December 15, 2009; 10:15 AM ET
Categories:  Health Reform  
Save & Share:  Send E-mail   Facebook   Twitter   Digg   Yahoo Buzz   StumbleUpon   Technorati   Google Buzz   Previous: Finishing what they started
Next: On cost control, the theory is try, try and try again


Umm...don't count your chickens. The bill hasn't even passed the Senate yet.

Posted by: MBP2 | December 15, 2009 10:25 AM | Report abuse

Kos is right! You think republicans are going to add anything in 2011 when they run the place?

Posted by: obrier2 | December 15, 2009 10:28 AM | Report abuse

In order to keep Joe Lieberman from doing any more damage, my official stance is "I am a liberal and I hate this bill! Man, it's awful! There's NOTHING left for me to be excited about! Bummer!"

Posted by: cog145 | December 15, 2009 10:30 AM | Report abuse

Any bill with a mandate that does not also include a gvmt option (i.e. public option, medicare-buy-in) is nothing more than corporate welfare and a major sell-out by the Democratic party.

This bill will do nothing except funnel more money to the insurers. There are enough loopholes in the bill to ensure the status quo regarding pre-existing conditions, recissions, coinsurance and annual caps.

Posted by: Lomillialor | December 15, 2009 10:30 AM | Report abuse

This post should be re-posted every day until it passes to calm people down.

Posted by: mschol17 | December 15, 2009 10:31 AM | Report abuse

You still don't seem to get the big picture, EK. All the rich white men in DC play their little games, do the bidding of their corporate masters, and expect people to vote for them. But the bottom line is that "the base" is going to close their wallets and stay home next year, no matter what "it is better than nothing" analysis you put forth. And when the purity-test Republicans come in, things will be much, much worse.

But of course, none of this matters to the millionaire Senators. They don't want to be mean to Holy Joe and take away his privileged positions. And the rest of us will continue to be screwed as insurance companies find ways around the legislation they got.

Posted by: AZProgressive | December 15, 2009 10:32 AM | Report abuse

Here's what real progressives are saying, not the DLC type: If the Senate bill is the final bill, Darcy Burner, the Executive Director of the, says kill it:
The first rule of medicine is, "Do no harm." The post-Joe Lieberman version of the Senate healthcare bill fails that basic criterion. Unless Democratic leadership steps up to fix this misguided proposal, our only recourse will be to kill it.

The fundamental failing of the newest Senate proposal is that it requires individuals to purchase health insurance, but does nothing to rein in what insurance companies charge. There is nothing to stop spiraling health costs from eating up an ever-increasing percentage of our national productivity.

The House bill has two major cost-control mechanisms: the public option and the 85% medical-loss ratio requirement. The Senate bill is on track to have neither, and nothing new to replace them. The Senate bill is a recipe for national disaster. If it's that bill or nothing, I prefer nothing.

Posted by: obrier2 | December 15, 2009 10:35 AM | Report abuse

Such confidence that this will in fact improve people's access to medical care!

Have none of these policy people ever had to deal with a for-profit bureaucracy?

The insurance companies have zero incentive to pay out anything for care -- they will, as now, pay only what regulators force them to pay. And this process has demonstrated that our ruling class has no interest in fighting the insurance companies, ever. This is not confidence inspiring.

Posted by: janinsanfran | December 15, 2009 10:36 AM | Report abuse

I'm fairly progressive and I'm fed up with the self-defeating attitude I see coming out of the Left. People are already talking about Republicans taking over in 2011, and killing this thing because insurance companies stand to profit from it. Was that ever in doubt? Jeez.

This is what progress looks like. It's not glamorous. Even if we got everything we wanted the fight over coverage and cost isn't nearly over, let alone the root causes of poverty and ill health.

Buck up, lads. Grow a pair and keep fighting. Don't let the selfish and simpleminded win again. This is going to get more coverage to more people for less money (eventually). The end.

Enough already.
We win if we say we win. I say we won.

Posted by: itstrue | December 15, 2009 10:38 AM | Report abuse

You were stronger with your rhetoric against Lieberman than you were with Kos, even though your moral logic condemns them equally. Be consistent.

Posted by: jamusco | December 15, 2009 10:38 AM | Report abuse

--"Since we talk about the costs of health-care reform over a 10-year period, may as well talk about the lives saved that way, too. And we're looking, easily, at more than a hundred thousand lives, to say nothing of the people who will be spared bankruptcy, chronic pain, unnecessary impairment, unnecessary caretaking, and so on."--

A program that will suck trillions out of the economy (out of real people's pockets) will result in a lower standard of living for millions. It's the road to hell, and it's paved with the ignorant intentions of small minded busybodies.

Posted by: msoja | December 15, 2009 10:42 AM | Report abuse

Please don't calm down, Kos! Nothing can do more than your sustained, hyperbolic hatred of this bill to secure Lieberman's vote and avoid further compromises.

Posted by: eleander | December 15, 2009 10:56 AM | Report abuse

Good Defense.

Now - what did you say about that 'cost control' so that we start our daily music again?

The specific question I am still interested is how 'competent Medicare Commission' is proposed. Does the rate of increase in order to accept the commission recommendations still need to be 'Medicare greater than general health care cost' (which happens very very rarely) or we will get 'Medicare growth rate larger than general growth rate' (which is what always happen)?

The reason is Sen. Reid has his dirty hands all over the place - one of that being 'weaker Medicare Commission'. Without a strong commission, no matter how eloquently Ezra praises this bill or Obama exhorts on National Mall; we are setup for the failure.

I say Sen. Reid's hands because original Baucus bill did not have PO and Sen. Reid poisoned the well further by introducing it so as to shore up his electoral chances back home. He is the real mess in all this, with no foresight and no leadership. Not that the next man (and possibly the next Senate Majority Leader) Sen. Schumer is coming clean here - he too wasted lot of precious hours of Congress by dangling unachievable PO.

In short the bill is good, but the Senate Dem Team sucks. Say what, the House bill is weaker but at least they do not get the blame of wasting 'national political zeitgeist'. HCR sausage making has become a pathetic game of 'old white men fighting for a piece of stale, rotten meat'.

Posted by: umesh409 | December 15, 2009 10:57 AM | Report abuse

Part of the answer I suppose we will get when we get the CBO score today or tomorrow...

Posted by: umesh409 | December 15, 2009 10:59 AM | Report abuse

So, I'm wondering where this Klein Doctrine of massive intrusion into the lives and livelihoods of the earnest citizenry in order to "save lives" is enumerated in the Constitution. Is there any rhyme or reason to it? Or is it based on whatever flaps into his head at any given time?

Posted by: msoja | December 15, 2009 11:02 AM | Report abuse

The only way to redeem this sell-out is to raise tax rates on the rich and get some of their profits back for the people.

Posted by: Mimikatz | December 15, 2009 11:05 AM | Report abuse

I think we need a law that forces people to move away from the coasts, especially the Gulf coasts. Think how many lives would be saved! And it won't add to the deficit!!! Throw 'em in jail and confiscate their assets if they don't comply.

It's the Klein Doctrine.

Posted by: msoja | December 15, 2009 11:06 AM | Report abuse

Hey, msoja, the 1920s called. They want their discredited Republican ideology back.

Posted by: redwards95 | December 15, 2009 11:08 AM | Report abuse

Ezra is being contradictory.

First he states that Liebermann's hatred of the public option and medicare-buy-in are based solely on his desire for revenge against liberals and that he (Ezra) can't figure out an alternate explanation for Liebermann's actions, but then he says this....

"On its own terms, the bill is the most important social policy achievement since the Great Society."

Well, Ezra, if you truly believe that, then you can't very well claim that Liebermann's hatred of the gvmt options are mysterious because obviously Liebermann thinks they are wasteful (or duplicative, or expensive, or something to that affect).

Posted by: Lomillialor | December 15, 2009 11:10 AM | Report abuse

"morally unconscionable for Joe Lieberman to put the bill at risk over something as small as Medicare buy-in for 3-or-so million people"

1. Then isn't it also "morally unconscionable for [proponents] to put the bill at risk over something as small as Medicare buy-in for 3-or-so million people"?

2. He got his way after a mere few days of folderol. Nobody at risk. Calm yourself.

Posted by: ostap666 | December 15, 2009 11:12 AM | Report abuse

I sure feel better having smart guys like ezra protecting humanity. i hope he thinks i am a moral person, like he is. although i wonder if him pimping himself on olberman is the moral equivalent of lieberman killing 150k people.

Posted by: sbass | December 15, 2009 11:16 AM | Report abuse

We need to outlaw swimming and boating and skiing and, probably, driving. And certainly eating fast food is got to be ended. How many useless deaths must we witness before Klein advocates the change we need?

Posted by: msoja | December 15, 2009 11:18 AM | Report abuse

Ezra, the battle was for single payer, or a similar universal system. There is no longer any progress towards that end, not even the token a public option or the fig leaf of medicare expansion.

That is a total, abject and humiliating failure.

Posted by: adamiani | December 15, 2009 11:31 AM | Report abuse

I think it would be useful to talk a little bit about what kinds of regulatory oversight there's going to be over the private insurers (esp. in the exchanges). While the insurance reforms are a good start, they're also a pretty specific list. There's nothing stopping the insurers from finding new ways to shed risk. I think many progressives worried about the structure of this bill might be encouraged to hear a little big more about when (or if) the government can come down on an insurer acting that way.

Posted by: NS12345 | December 15, 2009 11:42 AM | Report abuse

So many people in this debate (and in this thread!) have gone so crazy about reform that I'm glad there are people like Ezra posting some good ol' reason.

I hate this bill. It's a lot of money sent to insurer's profits. It doesn't have the expansion of the government role in healthcare that I think is essential in the long term. It doesn't provide enough in subsidies.

But also, this bill will save lives. As Ezra's been posting for the last several days, this really isn't controversial. Thousands of people are dying every year because they lack access to health insurance. This bill makes that situation better.

And as to Ezra's rhetoric vs Leiberman and Kos: Leiberman is an elected Senator who has made himself the lynchpin of reform. Furthermore, Kos (and other liberals who think we should kill this bill) are overreacting emotionally to a strategic loss on a minor part of the bill by believing incorrectly that there is nothing left in this bill that can't be gotten in a better bill later. Leiberman is reacting to a minor part of the bill with outright falshoods, making it apparant that there's no real basis for his opposition other than personal issues.

I think Ezra's posts aren't *that* different in what they say about Leiberman and Kos, but if he seems slightly more ticked at Leiberman, maybe it's because one of the two is a guy with a popular website and the other is an voting elected official whose caprise directly led to good policy being removed from the bill.

Posted by: MosBen | December 15, 2009 11:43 AM | Report abuse

Actually, assuming Lieberman can read the politics as well as Reid or anyone else, he wasn't actually putting the bill at risk. He had a completely free pound of flesh he could extract and he did. Once he made his demands, the choice was keep working on the bill until it's too late in the 2010 cycle to both pass and defend it or get something done now. The preference on what to do was obvious, but annoying. I assume that even if you don't read the politics astutely, those in Washington can get to someone else who does.

Posted by: windshouter | December 15, 2009 11:49 AM | Report abuse

Funny, but the article ducks things like Lifetime Limits, Free Rider, and all the other "bad" items in the bill.

Ezra is the opposite of Lieberman. For Joe, it's keep anything bad for Big Health out of the bill. For Ezra, it's getting more people covered, even if via bad policy and with a bill that has more bad things in it than we could have imagined at the start of the process... and which Ezra at this point won't even take the time to list.

"Coverage at any cost."

Of the two, Ezra's is the more noble position. But it doesn't make this a good bill.


Posted by: toshiaki | December 15, 2009 11:51 AM | Report abuse

"We need to outlaw swimming and boating and skiing and, probably, driving. And certainly eating fast food is got to be ended. How many useless deaths must we witness before Klein advocates the change we need?"

Argument by hyperbole is for people who have nothing else. There is a space between unfettered freedom and total tyranny. It's called life as we know it.

We don't outlaw driving. We mandate seatbelts and speed limits. We don't censor points of view. We just call them stupid when they are.

Posted by: itstrue | December 15, 2009 12:11 PM | Report abuse

Ezra, your post above is meaningless without answers to the following kinds of questions, and the fact you have boldly claimed "this bill is the most important social policy achievement since the Great Society" implies you think you know the answers to these questions.

The following questions are regarding a bill without a public option or medicare-buy-in:

- Can insurers set arbitrary annual and lifetime maximums?

- Can insurers set arbitrary coinsurance and deductible levels?

- How will this bill reduce costs for the government and individuals? How much in the first two decades? Will premiums instead rise?

- What percentage of Americans will have adequate insurance ten years from now (if this bill remains unchanged in that time)?

- Will insurers be able to reject applicants because of pre-existing conditions? If not, why then the perceived need by Democrats for medicare-buy-in or the public option?

- Will insurers be able to withhold medical payments for the sick (recision)?

- Will this bill substantially reduce the number of Americans who go bankrupt because of medically-related expenses and also reduce the number of deaths due to people being uninsured?

Posted by: Lomillialor | December 15, 2009 12:18 PM | Report abuse

Gosh, does this mean we're not moving fast enough toward communism?

Posted by: BillCarson2 | December 15, 2009 12:24 PM | Report abuse

Thank you Ezra and, who knows, maybe Kos is just trying to make sure that Joe doesnt think the left is happy with whats left.

Posted by: gregspolitics | December 15, 2009 12:36 PM | Report abuse

I hope to god they kill this bill and try again from scratch in 2010. With an open and transparent Obama promised. A new bill needs to start at the Center and build outward; by the Center, I mean priority #1 is cost-containment. Getting the total cost of health care spending down, to the point where it's affordable for most...and subsidized for the underclass and lower middle class. IMO the answer is moderately high co-pays and premiums, and elmination of routine low cost stuff (like oil changes for your car), with a focus on protection against catastrophic illness.

Posted by: JohnR22 | December 15, 2009 1:19 PM | Report abuse

msoja posted: "Since we talk about the costs of health-care reform over a 10-year period, may as well talk about the lives saved that way, too. And we're looking, easily, at more than a hundred thousand lives.

My god I'm sick of the Left pulling this emotional horse%(*#&(. Every time they can't get their way they bleat about "saving the children" or they trot out some pathetic wretch with a uniquely bad story and try to emotionally blackmail us into supporting their lousy legislation. Well here's a question pal; how many people die each year in car accidents? Or from accidents? Or from choking on a ham sandwich? If it's all about SAVING LIVES...then I guess we need a govt bureaucracy for each of them to save us from ourselves. It is not about saving every single #%(&)(#% life; it's about having an affordable system that provides the maximum benefit to the maximum number given the funds available. That's the problem with the Left; they won't acknowledge resources are limited...SKY's THE LIMIT as far as they're concerned.

Posted by: JohnR22 | December 15, 2009 1:24 PM | Report abuse

"Every time they can't get their way they bleat about "saving the children" "

We've spent the last 7 1/2 years of the previous administration using 9/11 as an excuse to "keep us safe" while they sent good men and women off to die, created a whole new govt agency, and ran up the deficit all so they could line their and their friends pockets. That's called providing the maximum benefit to the minimum amount. Give me a leftie over that anyday.

Posted by: caed | December 15, 2009 1:40 PM | Report abuse

sure ezra, lets spend 100% of our wealth on health care why dont we? that way no one will die or anything, ever, prematurely or otherwise.

this bill doesnt provide universal coverage, how many more hundreds of billions will be sought for universal coverage?

how many more hundreds of billions we be sought to expand the SCOPE of coverage, both pre-existing this bill, mandated by this bill, and mandated by future bills to provide universal access?

where will this money come from. The Chinesse? how much interest will we have to pay to the Chinesse to service that debt? how much will that crowd out equally as vital national priorities?

bottom line: we have an entitlement culture that we cannot afford and Obama's presidency will go down in infamy for blowing the chance to stop the tide of this culture. he promised to be responsible, and he is acting the exact opposite.

he needs to go, along with harry reid and nancy pelosi.

Posted by: dummypants | December 15, 2009 1:49 PM | Report abuse

Ezra, you're are just plain wrong when you say that this bill will prevent people from going bankrupt. Sure, subsidies will help some people afford coverage, but some people will still go bankrupt based on their specific medical issues. When you repeat over and over again that this bill will prevent people from going bankrupt without indicating the specific wording in the bill which makes this so, you undermine your own credibility. I'm not even sure that President Obama makes this claim anymore at this late date.

Posted by: goadri | December 15, 2009 2:59 PM | Report abuse

Are we going to end up with a real Healthcare bill that favors its citizens or another give away to Pharmas and the Insurance Industrial Complex?

Posted by: bobswire | December 15, 2009 3:38 PM | Report abuse

There is one thing in which I have complete confidence....the ability of the Insurance Cabal to find creative ways to enjoy the largesse from the premiums of "required coverage" while continuing to find ways to avoid providing the coverage needed by rate payers. And once again, the working middle class takes it on the chin and keeps working to pay for the excesses of the gilded class and for the widows and orphans.....And when there is no more middle class? no worries, American corporations are already counting the "consumer base" in China. They have all they want and need from America. Despite all their cries against regulation I notice none of them rushing to give up their "corporate citizenship" or incorporation in America....nope, our regulations and legal system has been custom crafted to suit their needs. Shame on Senate Democrats AND President Obama...we used to have "for profit" firefighters too....Not EVERYTHING has to be designed for corporate profits.....especially when it's supposed to provide "essential services". We are, I believe the country founded on the right to "life" as well as "liberty and the pursuit of happiness".....

Posted by: carolina4 | December 15, 2009 4:30 PM | Report abuse

It is clear that this bill should not be passed. North Dakota citizens have been working hard to get their elected officials to listen to them but so far they continue to ignore them. Byron Dorgan who doesn't even live in North Dakota continues to ignore the people who trusted him to represent them. North Dakota Senate candidate Paul Sorum is gaining momentum in the state due to moves like this by Dorgan. Sorum is leading a rally outside of Dorgan's office on December 16 to try and get the Senator to finally listen. We don't want government ran health care. Paul Sorum is the kind of leader who gets it.

Posted by: ScottPapelbon | December 15, 2009 6:05 PM | Report abuse

"But the other piece to remember is that more than it's a good bill, it's a good start"

I keep hering this as though from people who think that magically in the future this bill gets better. I don't think so. Likely, democrats lose seats next year because of low turnout by the base, and the bill gets worse. In fact, I could see this bill becoming the insurance industry's wet dreams. Millions of forced customers and no cost controls. Cable monopolies would love that same deal, but why would I or anyone else? Finally, true bipartisanship, liberals and conservatives say, "Kill this bill!"

Posted by: rodneythecat | December 15, 2009 7:42 PM | Report abuse

This bill is a monstrosity. The civilized world long ago adopted single payer systems which save lives at a low per capita cost. The American people no longer have representation in Washington. This bill does nOTHING to contain cost and is nothing but yet another giveaway to the health care leeches.

Profit has no place in health care.

Posted by: bigbillhaywood | December 16, 2009 12:31 AM | Report abuse

Bigbill whatever... you must not have read this bill nor have you read the comments of several dozen major economists AND the CBO who say this bill will contain costs. It's not perfect but it has many pieces in it that will help reform the way we pay providers and that will ultimately bend the cost curve.

Posted by: LindaB1 | December 16, 2009 1:19 AM | Report abuse

ScottPapelbon, you said:

"We don't want government ran health care. Paul Sorum is the kind of leader who gets it."

You do know Medicare is government run health care, don't you?

Why are teabaggers so dumb?

Posted by: reach80 | December 16, 2009 4:46 AM | Report abuse

rodneythecat, you said:

"In fact, I could see this bill becoming the insurance industry's wet dreams."

So why is the insurance lobby running commercials calling on congress to kill the bill?

If this bill is so favorable to the insurance industry, why are they opposed to it?

Posted by: reach80 | December 16, 2009 4:50 AM | Report abuse

Not to compare apples to oranges or anything...but with all of this yammering about these health reform costs I am about to get sick...and I don't even do politics.

Does anyone happen to know what the US government has spent on the National Defense Budget as well as additional war supplemental? Anyone? Well, I was curious, so I decided to do some research to find out how much we spend to potentially and actually kill people.

from 2000-2009 (only nine years mind you) the US government has spent over $5.7 TRILLION. By the tenth year it is projected to be over 6 TRILLION. I don't really hear any complaints about those numbers. Why doesn't the news and the conservatives carry on about that? That is approx. SIX times the amount of taxpayer spending over the years that this health care reform bill is projecting.

So since some of you don't care about healthcare for everyone and are just concerned on how you can benefit from the status quo, maybe when you are in the hospital, I will not care about you. I am your nurse and frontline patient advocate...and guess what? I don't even have insurance for myself.

Posted by: sassypants1 | December 16, 2009 12:58 PM | Report abuse

I voted for Obama to escape the political equivalent of gang rape by the Republicans only to seduced and abandoned by the Democrats. Either way, I am f$%&ked.

Posted by: rtuoni | December 16, 2009 6:06 PM | Report abuse

Man. The left were actually pushing a really useful, constructive argument in this debate and FINALLY getting engaged enough to make a difference on a point that had some hope of passing, and then they fly out into totally unproductive cross-bearing.

I'm a big old liberal. I protested against entering Iraq, supported Dean in 2004, donated money to Ned Lamont, and had way too many arguments with DLC types who accused me of being a naive leftists. And I think Obama has definitely made mistakes in framing and selling this thing.

But I'm having trouble really taking progressives who claim to be terrified about a bill that gives us universal coverage, better insurance regulation, Medicaid expansions, and a path to Medicare solvency. ESPECIALLY when they claim they had been totally ok with this when the useless, withered appendix of Harry Reid's public option was still in the bill. Come on, this is about proving a stupid point about "how well government can work," not lives or "rights" or any of the stuff they bluster about. Well y'know, pushing a bill right up to the finish line before falling over our own shoelaces and crying about it sure proves that point more than anything the statute could say.

Posted by: NS12345 | December 17, 2009 1:50 AM | Report abuse

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