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How does Washington decide what insurance is?

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The best exchange of the day came moments before the attendees at the Blair House summit broke for lunch. "There is a philosophical difference," Rep. Eric Cantor said. "There is a fear that if you let Washington define what essential health benefits are, there won’t be an end to that."

But is this a philosophical difference? When I interviewed Rep. Paul Ryan, who's one of the Republican participants at the summit, I asked him how his health-care plan ensures that people can trust that the coverage they're buying won't let them down when they get sick. "In the Patient’s Choice Act," he explained, "we do an actuarially equivalent minimum in each exchange that’s equal to the Blue Cross/Blue Shield Standard Option." That seems a lot like how the Senate bill works, I said. "You need to define what insurance is," Ryan replied. "I agree with that."

Everyone agrees with that, in fact. The Wyden-Bennett bill, which many Republicans have co-sponsored, also sets up a basic benefit equivalent to the Blue Cross/Blue Shield Standard Option (politicians like to use this because it's the basic insurance offered in the Federal Employees Health Benefit Program, which all of them use). Similarly, Republicans favor a policy to sell insurance across state lines. That would also mean that there is a single national standard for insurance -- but rather than being decided by Washington, it will be decided by whichever state has the most lax insurance regulations. We'd have a national standard being written by South Dakota's legislature, which would be a strange fate indeed.

Whoever writes the definition, however, both sides agree that someone needs to do: Insurance is a complicated product, and if it's deceptively sold, it can cost people their lives, or their homes. Most of us are not professional actuaries; it's hard for us to truly understand what's contained in the dozens of pages of fine print that our plans contain. We outsource that job to regulators who, we hope, will do some of the work for us. It's not ideal, but it's better than the alternative.

Philosophically, Republicans do have a disagreement with this. It's regulation, after all. But in practice, they accept it. When Republican passed health savings accounts into law, they included definitions of the minimum standards a plan had to meet to qualify. When they passed the Medicare Prescription Drug Benefit into law, they defined what a plan would have to do to qualify for the program. Philosophy is important, but when you're passing legislation, it takes a back seat to making the policy work.

The Senate health-care bill (pdf) explains how it will define essential benefits in Section 1301. It's not particularly detailed:

The Secretary [of Health and Human Services] shall define the essential health benefits, except that such benefits shall include the following general categories and the items and services covered within the categories:

(A) Ambulatory patient services.
(B) Emergency services.
(C) Hospitalization.
(D) Maternity and newborn care.
(E) Mental health and substance use disorder services, including behavioral health treatment.
(F) Prescription drugs.
(G) Rehabilitative and habilitative services and devices.
(H) Laboratory services.
(I) Preventive and wellness services and chronic disease management.
(J) Pediatric services, including oral and vision care.

The other requirement is that the plans have to fit one of the four actuarial values in the Exchange (an explanation of actuarial values). This is, well, a pretty general definition. It doesn't define how your insurance will work. it sets a floor that says insurers have to cover the basic array of things a person needs, and they need to cover a certain percentage of the costs people are expected to need covered (either 60 percent, 70 percent, 80 percent or 90 percent). But beyond that, it's left to the secretary of Health and Human Services.

The reason it's left to the secretary is because, as one Senate aide explained, "legislation is harder to change." If a future Republican administration wants to add a new type of consumer-directed insurance plan to the exchanges, they have the power and flexibility to do so. If an insurer wants to propose an innovative product legislators never dreamed of, the secretary can give them the go-ahead. If the legislation defined any of this precisely, all that would be impossible.

You may ask, of course, why the Secretary needs to be involved at all. Why not just let insurers add products on their own? The answer, basically, is that they'll need technical issues clarified. "When you say the plans need to cover emergency services," the aide says, "health insurers will want to know if an insurer can use financial incentives to encourage people to use primary care rather than go to the emergency room." That's freedom we want to give them, which means we need a human being in the process able to interpret the legislation in light of its goals rather than just in light of its words.

Democrats are trying to strike a balance between offering necessary definition and protections and making certain that insurers can continue to innovate. That's a delicate project, and Republicans can certainly disagree with the precise way that Democrats propose to achieve it. Maybe they don't think that insurers should have to cover pediatric services, for instance.

But there is no disagreement over whether someone needs to define, in broad terms, what counts as health-care insurance. Republicans do it in their bills, Democrats do it in their bills. Cantor is creating a philosophical dispute out of something more properly understood as a practical question, and it's much harder to compromise between philosophies than over operational details.

Photo credit: Scott Loeb/Getty.

By Ezra Klein  |  February 25, 2010; 2:13 PM ET
Categories:  Health Reform  
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Comments

I was a 'professional actuary'!

The reality is that some people sell 'insurance' that is really a discount card. You pay for buying into a network, and they pay nothing for costs.

It is deceptive. It's all deceptive. In this country, we make more money through deception than competitive advantages. Competitive advantages are usually wiped out in the matter of hours now-a-days.

Where are the high margin businesses in this country? Oil - monopolistic. Rx - not a true market in any way. Health ins - not a market either, buyer isn't payer. (Ask bill frist's family). Finance - deception is key here. Gov (defense) contracting - buyer isn't payer.

Any consumer oriented 'real market' products are all low margin anymore, except Apple products. Even they will get cut into soon.

Posted by: rat-raceparent | February 25, 2010 2:53 PM | Report abuse

Nice post explaining this topic.

I'd add that the approach used in the current legislation-- broad category definitions plus actuarial value isn't the only way to go. In fact, I'd argue that this is the conservative way to go. Back a few years, CATO was arguing that universal insurance/mandates would require benefits to be defined by government-- but of course, that isn't the case. You can focus on degree of financial protection, i.e. actuarial value, without really getting into specifics on benefits-- which addresses CATO's concerns.

There are other ways, however. In Massachusetts, they have a more liberal, government-oriented approach. They use the broad categories (they actually may be exactly the same), but rather than focus on actuarial values, the "Mass Health Connector" has to actually approve individual plans to ensure they meet their interpretation of basic benefits under the broad categories. That's a heavier hand of government oversight.

In other words, similar to other components of health reform, the proposed legislation is already so far at the conservative end of potential proposals that are feasible to having a well-functioning private market, that Republicans are left with resorting to proposals that provide so little oversight that a meaningful marketplace isn't feasible.

I'd just add that part of the problem is the mere lack of knowledge by our political leaders on these specific issues. Cantor probably isn't aware of a) the level of oversight provided today, as described above b) what minimal level of oversight is needed to have meaningful competition c) what models are available for policy options. That's a major problem for this whole debate.

Posted by: wisewon | February 25, 2010 3:02 PM | Report abuse

Agreed, there is a lot of deception out there. You have to be on your toes.

I was browsing fund options at Fidelity the other day and saw this: http://personal.fidelity.com/products/funds/mutual_funds_overview.shtml.cvsr

They have something called enhanced index funds. They are like index funds, but managers use computer models and other tools to overweight stocks they think will do well and underweight stocks they think won't do quite as well. Your fee is increased for this priviledge (0.07% to 0.45% to go from the S&P500 index to the enhanced large cap core index).

What these are are basically managed funds. Instead of tracking an index, a manager can use discretion to try and beat the index. However, the whole point of indexing is that most managers fail to beat the market, you can't reliably determine the best fund managers ahead of time, and you get charged more in the managed fund. They're using the name 'enhanced index' because lots of people who know a bit about finance might have heard of the advantages of using index vs. managed funds. For the record, the regular index has done better over the past year than the enhanced index fund.

Posted by: justin84 | February 25, 2010 3:12 PM | Report abuse

Lets face the FACT: Republicans are utter complete lying lunatics, that is they say they want to "reduce the Deficits", "they are worried about the debt bomb..", etc. But if you really want to really reduce the Deficits then you would be for greatly reducing health care costs which means then you would be for Universal single payer health care.

Because in every European country, Canada, Israel, etc. whom have single payer health care, health care on average is taking about 9% of the GDP, while the US for profit health care is taking 18% of the GDP, here:
http://en.wikipedia.org/wiki/Health_care_in_Canada

How is it that Universal nationalized single payer health care will SAVE us about 50% compared to the current for profit health care system WHILE giving every American free or very affordable health care like $59 per month as in Canada, for the Taxes that we (already) PAY? Answers:

1st- The way Universal Nationalized Health Care is operated in Europe, Canada, Israel, etc. is the same way we operate the Military, Police, Fire Department, Courts of Law, etc. etc. in US. That is these important services are paid for mainly from our Taxes, and the salaries of people involved in them is set by our Government (Federal or State). So the same way that our Government sets the salaries of a 4 Star General or an Admiral or a Federal Judge is the same way that the Governments in UK, Israel , etc. sets the salaries of Doctors, Nurses, etc. working in their Universal Nationalized Health Care system.

2nd- No one working in the Universal Nationalized Health Care system will be able to get paid $50Mill per year and fly in $100Mill private Jets as is the case with the top brass of the Big Pharma, Big Insurance, etc. in the US. And equally as important, No Health care provider can go public and thus generate 100s of Millions of Dollars in listing fees for the Wall Street bankers and pay 100s of Millions of Dollars per quarter to the Wall Street gang in the form of dividends, preferred shares, etc.

More here:
http://anoox.com/blog/UHC.38349

Posted by: RealNews1 | February 25, 2010 3:15 PM | Report abuse

The President expressed an interesting figure this morning: 44 out of 50 states (88%) have decided not to implement insurance standards as lofty as those now proposed by the Democrats controlling the Federal Government.

Of the 88% (44 out of 50) states which have decided not to implement the lofty standards, all have higher citizen lifespans than 5 of the states that do (Hawaii being the exception).

Posted by: rmgregory | February 25, 2010 3:19 PM | Report abuse

All the philosophy before later Wittegenstein (Philosophical Investigations) was about 'how many angels on the tip of a needle'; meaning useless; philosophical debate out of thin air about nothingness.

Cantor needs to read later Wittegenstein.

Meaning of a word is 'how we use it', as simple as that.

Meaning of a legislation is who can use to define 'contracts' and 'execute transactions'. If a law does not help me to conduct a transaction between two free agents of the State who subject involuntarily to sovereignty of State; that law is useless.

Law's usefulness cannot be simply number of pages it needs to define. If you are challenged 'to read' legislation in modern society, then that is not our problem. It is Tea Party which wants to perpetuate the myth that with one page document they can conduct 'complex transactions' in today's world. Myself and most Americans do not want to succumb to such 'foolish' simplicity which deprives us from transacting meaningfully in today's world.

Posted by: umesh409 | February 25, 2010 3:20 PM | Report abuse

Letting an arbitrary individual (Secty of HHS) or a governing body establish essential health benefits, even at a minimal level, ends up creating a "one size fits all" and often results in higher costs for large groups of people.

For example, your list of 10 categories contains 3 areas where I don't require services or benefits. A policy required to include all 10 would have services I wouldn't ever use and likely be at least 30% higher in cost than I should need to pay. In addition, I can easily budget for routine doctor visits and don't require benefits for those services either.

Bottom line, without considerable flexibility on the part of the insurance companies to design and build products that provide choice to consumers, you are going to have many overpaying for unneeded benefits and some not getting the benefits they do need.

Your article indicates that this is done to protect the consumer from the evil, deceptive insurance companies...in other words to "protect us from ourselves". This can't be done and is rarely ever successful.

By the way, I've never been deceived by an insurance company...but I have been deceived on numerous occassions by unscrupulous politicians and their government programs.

Posted by: cdgolding | February 25, 2010 3:22 PM | Report abuse

Rep. Eric Cantor said. "There is a fear that if you let Washington define what essential health benefits are, there won’t be an end to that."

Your whole piece is based on the jump that Rep Ryan's willingness to consider the federalization of healthcare means there is no point to ponder the original merits for and against federalizing healthcare.

As much as I PREFER Ryan or Feldstein's proposals for healthcare, I am scared to death of this kind of federalization. We DO NOT EVEN FEDERALIZE EDUCATION and there are significant disputes between everybody's munipally run board of education and their communities----in certain townships of the country wars beak out figuratively speaking over spending vs. quality.

A FEDERALIZED HEALTHCARE will be much tougher to fight at the ground level than the local educational systems are at the municipal level and far more risk of detachment by cold bureacrats in DC!


This is a REAL GOOD PLACE TO START THIS DISCUSSION!

Posted by: FastEddieO007 | February 25, 2010 3:30 PM | Report abuse

Ezra writes:
~~~~
Whoever writes the definition, however, both sides agree that someone needs to do: Insurance is a complicated product, and if it's deceptively sold, it can cost people their lives, or their homes.
~~~~

If the federal government were to regulate responsibly it would solely target its regulation to prevent insurance from being "deceptively sold"....the legislation takes on much much more than this, it defines the business model for what insurance can look like. Obama's new "compromise" even gives federal government control over what it can cost.

Posted by: FastEddieO007 | February 25, 2010 3:34 PM | Report abuse

Ezra's point is that everyone agrees that someone needs to define what the minimum level of coverage is. The Republican proposal to allow insurance across state lines just means that the person deciding what the minimum is is whichever legislature ends up being the most desirable to insurance companies or, as was the case with the credit card industry, the industry themselves. *Someone* is going to make this decision and it's not going to be an individual consumer. So it's not a philosophical difference about the need for such a definition, it's a practical difference about who should make that decision.

Posted by: MosBen | February 25, 2010 3:50 PM | Report abuse

to rat-raceparent:

great points. couldn't agree more.

i own a small business and have come to conclusion that most, if not all businesses use deception and not true "value-add" to make money. after all, isn't that the end-all of capitalism ... everyone surviving at the margins?

just another reason we can't rely on the "honesty" of insurance companies to provide good products.

Posted by: atv002 | February 25, 2010 3:50 PM | Report abuse

"Cantor is creating a philosophical dispute out of something more properly understood as a practical question, and it's much harder to compromise between philosophies than over operational details."

setting up the differences as "philisophical" is necessary for Boehner to stand up and say "NO" and then say, "Saying NO as a matter of principle is a good thing"...

And Durbin has just reminded the Republican teabaggers that malpractice is a straw man as suits have been cut in half as has the amount of awards in the past five years...

not that Republican teabaggers (blame Rich Lowry for this amalgamation not me) have shown any interest in facts in determining their approach to health care or anything else for that matter...

Posted by: teoc2 | February 25, 2010 3:52 PM | Report abuse

Insurance companies would be a lot more trustworthy without all of the Government insulation protecting them from the market. Perhaps real reform could remove that insulation instead of creating more of it.

Why would you trust politicians to cut costs when they deliberately pay above market prices for all Government services?

Posted by: fallsmeadjc | February 25, 2010 3:59 PM | Report abuse


In 2004, Larry Glasscock, chairman, president and chief executive officer for health insurer Anthem Inc., stands to receive $42.5 million as part of a stock and cash incentive deal.

The payout, according to documents with the U.S. Securities and Exchange Commission, are a result of Indianapolis-based Anthem's significant growth in recent years.

Terms of the deal call for Glasscock to get $21.2 million in a cash bonus this year, as well as restricted stock awards totaling another $21.2 million and another $101,868 listed as "other compensation."

Additionally, Glasscock received 2003 salary of $1.04 million, a bonus of $2.3 million and additional compensation of $273,000, according to the SEC filing.

Currently, Anthem provides health insurance services to 12 million people in Colorado, Connecticut, Kentucky, Maine, New Hampshire, Nevada, Ohio and Virginia. In Greater Dayton, the company has about 390,000 enrollees, good for No. 1 locally, according to Dayton Business Journal research.
------------------------------------------
As of April 2009, Angela Braly had the 306th highest compensation for a US CEO, having earned $4.07 million,[8] which is 74th among females.[9] She owns $4.6 million worth of WellPoint stock, or .02% of the company.[8] In 2007, Braly earned $14.86 million, mostly in stock options.[10]

Braly lives in Indianapolis with her husband Doug and three children, Tyler, Matthew, and Rachel.[11] She generally supports Republican political candidates with campaign contributions.[12]
-------------------------------------------
Where are the State Insurance Commissioners who're charged with regulating, and approving rate increases, for Insurance companies?
Why are State, and Federal Officials, "not'" doing what they're generally "overpaid" to do?
Below, is a report of Anthem./Blue Cross, and Blue Shield''s CEO'S' compensation for 2004.
With the CEO taking home 42 million Dollars, for one year's toil.
They should not need, nor be allowed to increase rates, for a ful decade. After such a payout, to one person.
If they can't survive on current rates, go bankrupt, someone else will start another Insurance Company.
But, my major point is, there''s an Insurance Commisiioner, somewhere, getting paid, and for what??
Dennis


Posted by: Shadowsmgc | February 25, 2010 4:19 PM | Report abuse

I hope anyyone who doesn't understand what's wrong with the system we have today -- particularly officials covered under the cushy federal plan who don't have a clue about what other people deal with -- will read this story by a former NYT reporter trying to get her private insurer to pay for her cancer treatment:

www.politicsdaily.com/2010/02/25/tom-k-working-insurance-nightmare-why-we-need-a-better-system/

Posted by: suzi01 | February 25, 2010 4:51 PM | Report abuse

"Major medical" was INSURANCE because it conforms to the same underwriting principles as fire insurance and auto insurance. One can't buy fire insurance while the house is burning and bad drivers pay more (are rated) for auto insurance.

"Medical" insurance is, in fact, a pre-paid medical service that does NOT conform to any insurance underwriting principles. The underlying idea behind insurance principles is replacing a potential large future loss (the claim) with a much smaller cost that is paid up front. "Real" Insurance never pays for routine (expected) costs or for pre-existing conditions.

Posted by: billwald | February 25, 2010 4:58 PM | Report abuse

"Insurance companies would be a lot more trustworthy without all of the Government insulation protecting them from the market. "

And your evidence for this is...?

Thought as much.

Posted by: pseudonymousinnc | February 25, 2010 5:15 PM | Report abuse

The Swiss, a bastion of capitalism if there ever was one, require everyone to have health insurance within 6 months of arriving. If we require everyone, including illegal aliens to do the same.....a lot of problems go away and no one feels taken advantage of like our good friends the tea baggers.

Posted by: katman13 | February 25, 2010 5:17 PM | Report abuse

A recent NEJM article reminds us that the most difficult decision is adjudicating the battle for health care resources between the uninsured and the overinsured. Our political process makes it possible for specific interest groups to politically guarantee access to certain treatments or therapies. By requiring certain benefits be covered, the cost of insurance for everyone goes up. The more services required, the costlier it becomes.

The health reform bills under debate defer the definition of “minimal credible coverage” to administrators within the Department of Health and Human Services. First, our society must come to grips with the inevitable truth that health care is a limited resource and decisions must be made regarding how much, to whom, and by what means to distribute this resource. We cannot realistically cover all things for all people. We should not cover all things for some people. The first priority of our healthcare system is universality. With that as a goal, difficult decisions about where to draw the line on benefits coverage must be made in such a meaningful way that funds allocated for health can cover some things for all people.

http://www.policyprescriptions.org/?p=725
NEJM. 2010. 362; 2: 95-97.

Posted by: CKDARK | February 25, 2010 5:20 PM | Report abuse

I don't see any need to ration services as much as I see the need for the healthcare industry to be more effective and efficient. In my experience, they are a bunch of goofs and provide substandard care. Why do we have to pay so much more per individual?

Posted by: katman13 | February 25, 2010 6:30 PM | Report abuse

We don' know exactly what the benefits will be, but we do know what the target cost is for the House Bill. $5000 per year for individuals and either $10,000 or $12,000 per year for families. Can't remember which at the moment. Those are the figures the CBO used for scoring.

And if you make over about %45,000 per year, you will be required to pay the whole $5000 yourself. And here a lot of you folks thought you were getting affordable health care. Surprise!

Several of the participants, including Cantor, questioned the need for such a costly package of benefits, and I totally agree with them. I expect that a lot of middle class Americans will once they are presented with the bill.

Posted by: bgmma50 | February 25, 2010 6:59 PM | Report abuse

Bg, the reason for a comprehensive full coverage plan is precisely because not everyone needs all that.

If you let healthy people by cheap low coverage plans you promote the freerider problem, just as if you let them buy no insurance at all. The whole point is that since everyone gets the expensive care when the poo hits the fan, everyone needs to be paying for that coverage. Otherwise only the very wealthy will be able to afford healthcare when they really need it.

Look at the insurance rate hikes around the country now. This is being caused by lots of healthy people droping insurance because of the expense during the recession. Thus leaving a sicker more costly pool of insured, thus requiring a premium hike, thus causing more healthy people to drop coverage...

Really people, its just like the fire dept. Everyone needs to pay their share or we will all suffer for it. Do you really want your neighbor to be able to save a couple grand by opting out of fire protection? what about the parent's where your kid is going for a sleep over?

Posted by: TisforTwit | February 25, 2010 11:57 PM | Report abuse

"If you let healthy people by cheap low coverage plans you promote the freerider problem, just as if you let them buy no insurance at all."

What do you think is going to happen when it only costs $750 to pay a penalty for opting out, and when you get sick you are guaranteed coverage despite your preexisting condition? Freeloaders, all aboard! Including me, perhaps. I can see absolutely no rational reason to obtain coverage under the Dem's plan.


"Really people, its just like the fire dept. Everyone needs to pay their share or we will all suffer for it. Do you really want your neighbor to be able to save a couple grand by opting out of fire protection? "

Where I live, fire protection is provided by Volunteer Fire Departments. My neighbors are likely to be volunteers, and I voluntarily contribute money every year to support them.

Posted by: bgmma50 | February 26, 2010 8:36 AM | Report abuse

"What do you think is going to happen when it only costs $750 to pay a penalty for opting out, and when you get sick you are guaranteed coverage despite your preexisting condition? Freeloaders, all aboard! Including me, perhaps. I can see absolutely no rational reason to obtain coverage under the Dem's plan."

This works for lots of things. Chronic things. Where it will fail you catastrophicaly for your finances is that when you get hit by a car, you can't sign up right before that. So much or all of the cost of that injury will be on you.

The second piece is that the weakness of the mandate is from conservatives who oppose it all together. It's just simple math, if everyone doesn't participate in PAYING, then virtually no one will be able to afford care. Seriously look at the rate hikes in CA and DC, that's market driven pricing folks.

"Where I live, fire protection is provided by Volunteer Fire Departments. My neighbors are likely to be volunteers, and I voluntarily contribute money every year to support them."

I have a hunch you aren't holding bakesales to by fire trucks. I suppose it's possible that your fire dept gets absolutely no tax money (well not really because they're going to have federal supports at the very least, things like death and disability for the fire crew.)

In any case, if you are in a subscription district and don't subscribe, that generally means anything not a threat to life, they won't come. This is precisely how fire departments evolved into being funded by taxes in most places.

The "hidden" benefit of funding a fire dept well is that your property insurance goes down. Insurance companies love a good fire dept. The "hidden" benefit of universal health care is (at least) twofold: 1) when you need health care it will be there and you will not have to trade in everything you have to get it. 2) You live in a healthier community. This has many benefits

Posted by: TisforTwit | February 26, 2010 10:27 AM | Report abuse

realnews1 wrote:"salaries of people involved in them is set by our Government (Federal or State). So the same way that our Government sets the salaries of a 4 Star General or an Admiral or a Federal Judge is the same way that the Governments in UK, Israel , etc. sets the salaries of Doctors, Nurses, etc. working in their Universal Nationalized Health Care system. **(HELLO!!!! WE DO NOT HAVE UNIVERSAL NATIONALIZED HEALTH CARE IN AMERICA....... YET!!!!!!!!!!!!!)

2nd- No one working in the Universal Nationalized Health Care system will be able to get paid $50Mill per year and fly in $100Mill private Jets as is the case with the top brass of the Big Pharma, Big Insurance, etc. in the US. And equally as important, No Health care provider can go public and thus generate 100s of Millions of Dollars in listing fees for the Wall Street bankers and pay 100s of Millions of Dollars per quarter to the Wall Street gang in the form of dividends, preferred shares, etc."

*********************************************

Only if the same rules apply to Washington Politicians. How about the American Taxpayers deciding on the Politicians salaries too. Also, maybe there should be an end to our Representatives spending over 9,000 an hour for a military flight to Copenhagen or anywhere else. I hope you like foreign medical personal. When our Politicians start dictating the salaries of our physicians and medical personnel, good luck finding an American RN or DR. to take care of you.. There is a shortage already and anyone who has had experience in our hospitals recently...can probably count on one hand the amount of medical staff with out a foreign accent. Hope you are good at reading lips.....

The last thing we should do is treat our Medical people like they are our servants. How dare YOU talk down to them like their knowledge isn't worth any money. The one's getting the big pay checks are CEO's, Administrators, Politicians, Lawyers, Bankers. If America chooses to treat our Medical staff the way you suggest.....then America deserves the third world health care you will all receive in return.

Posted by: Intuition1010 | February 26, 2010 8:49 PM | Report abuse

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