TCS Daily


Socializing Medicine in Three Easy Steps

By Max Borders - December 5, 2008 12:00 AM

The votes are in. America has chosen Barack Obama as President. Now America must live with its decision--particularly when it comes to Obama's grand strategy to kill private health insurance in America. Skeptical?

Campaign ads depicting Obama's health care plan as a "middle ground" might have lulled you into accepting the notion that it's a variation on the status quo. Hardly. Socialized medicine is the President-elect's endgame. And he'll get it. All it takes is three easy steps.

Step One: Ever hear of "guaranteed issue"? Obama's first step in a government takeover of healthcare is an insurance law that already appears in states like New York and Massachusetts. Guaranteed issue means insurers must cover anybody who wants to buy health insurance—regardless of their health status. That means people who chose not to buy insurance, but got sick, can then turn around and get insurance after the fact. Sort of makes the very idea of "insurance" kind of absurd. In any case, when an insurance company is forced to sell you a policy under any circumstances, prices go up for everyone else. Way up.

Insurance premiums in states with guaranteed issue are the highest in the United States. For instance, New Jersey's average monthly premium for an individual was $468 per month in 2007—that's twice the national average. That means there are, of course, more uninsured people than there would otherwise be (because more and more people can't afford the premiums). But making private insurance more costly is the idea, as we will see.

Step Two is to create a massive new federal health care program. Call it Obamacare. President-elect Obama, as per his campaign promise, will give people a "choice" between a new tax-subsidized federal program and what is left of private insurance. The former will be subsidized by taxpayers. The latter will be saddled not only with all the coverage mandates state governments already force you to buy (e.g. chiropractic, drug abuse treatment, etc.), but new federal mandates such as guaranteed issue and community rating. (Community rating is a mandate that says everyone pays the same premium, regardless of age or health status. Therefore, younger, less affluent people end up subsidizing older, less healthy ? but often more affluent ? people. That is, if they can afford it.)

Of course, no sane 23-year-old will "choose" a $400-plus per month insurance premium over whatever subsidized plan the government offers. And as younger people leave the private risk pool, older, sicker people will remain—driving up premiums more and more for those riskier folks who're left. Eventually, a steady stream of people will "choose" to abandon private health insurance altogether. And where will they go? Obamacare. All according to plan.

Bear in mind that under Obamacare, doctors and hospitals will presumably still be private. So we'll have a situation of socialized risk (insurance), privatized profit (providers) and a consumer free-ride. Sound familiar? Yes, it's the Fannie Mae and Freddie Mac model of health insurance. Within a couple of years, all that will be left of private insurance is a shell of what has always been an over-regulated health insurance market (though one that has lumbered along, anyway, giving U.S. citizens the highest quality healthcare in the world by far).

Which brings us to Step Three. We'll have Medicaid for the poor, Medicare for the elderly and Obamacare for everyone else. What do we call this trifecta? Socialized medicine. As people believe they're getting something for "free" they will consume, consume, consume—going to an MD at the slightest sign of the sniffles. The costs of health care will appear in the form of higher taxes. Doctors, facing an army of healthcare consumers with Obamacare expense accounts, will have incentives to treat patients, well, expensively. That is, until the proverbial chickens come home to roost.

Sooner or later, after taxes have gone up and up to meet demand for "free" healthcare, the government will run out of budget. They'll start rationing. They'll have to tell you what you can and can't have—just as they do in Britain, Canada and Cuba. In Britain, people wait 11 months for a hip operation. In Canada, the mean waiting time for psychiatric care is 18.6 weeks, 56 days for an MRI, 17.6 weeks for surgery. In Cuba the information is privy only to Michael Moore.

Want to wait months to see a specialist? Want to wait months to have your broken leg mended? Technological innovation, no longer driven by the right incentives, will stagnate. Drug development will be stifled as price controls come to town. Government-run healthcare will be a cross between medical triage and the DMV experience.

At least we'll have "equal access." At least that guy who goes without health insurance so he can blow his entire paycheck on clubbing, booze and cigarettes can see an MD at the first sign of sniffles. At least wealthy people will receive government-run care at everyone else's expense. No one will have to worry about making health care decisions any more. The government will make them for you--for better or worse.


Max Borders is executive editor at Free to Choose Network and adjunct scholar at the NCPA.

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64 Comments

I am for socialized medicine.
Before I get started, let me say the arguments for both sides are well known. I am mostly concerned at this point.

1. We have socialized medicine now, but at a much higher cost then it should be. If we gave up the required coverage regs, those costs go away.

2. The cost of an American car, and other American goods and services include a HIGH amount of health care embedded in the cost. We then have to compete with other countries that don't have these costs. Which is basicaly a tarriff on our own exports.

Its time to get over the fear and just do it.

Wow. Just wow. (Name that planet.)
Did you read and understand the article?

First off, what are you talking about, saying that we already have socialized medicine in one breath, and then saying that we don't, and should "just do it" in the next breath? Are you schizoid?

We do not already have socialized medicine, and if we did, there would be nothing to discuss (except, perhaps, how bad it sucks, and how we have to wait a year to see a doctor, who will then tell us that our medical problem is not covered under the government plan.)

What on earth makes you think that a government run socialized health care system will not have "required coverage regs"? Do you really believe that government stipulated health insurance will have LESS regulations than private health care?!?! What planet are you from? Have you ever worked with, or for, the government?

A private insurance company is looking for profit, so they put a lot of effort into streamlining their processes. They try to make their rules and regulations as simple and straightforward as they can, because they are the ones who have to use them, and they don't want to spend all their time arguing over stupid minutia. That is not way to make a profit.

A government agency, on the other hand, thrives on regulations. They are not motivated by profit - they get paid the same no matter how good or bad the customer service is. Instead, they are motivated by salaries, and the bigger your empire, the higher you go on the government pay scale. The more complex the rules and regulations are, the more people you can hire to interpret and implement them.

As for your second point - the cost of EVERYTHING manufactured EVERYWHERE includes the cost of the medical care of the people who produce it. Right? Where does the money for the medical bills of ANY employee come from? Ultimately, from the customers who buy the products that he creates. This is how it should be. This is true whether the company pays for the health insurance directly (through corporate sponsorship) or indirectly (through higher salaries so the employees buy their own insurance). Either way, the employee is earning his health care through his productivity. This is justice.

The opposite of justice is injustice. This is when a non-productive person, one who does not earn his health care by producing something valuable to the rest of society, is nonetheless demanding (and getting) his health care at the cost of everybody else. This is socialized medicine.

If you want American products to have a low medical cost included in the price, the only way is to produce low cost, high quality medical care for those employees.

The best way to produce low cost health care is to let the free market do it's magic. The only reason we have the best health care in the world is because the free market rewards hospitals, doctors, medical equipment manufacturers, drug companies who produce the best product at the lowest price. (What other reason do you think American medical care is so good? Did you think it was because Americans were somehow superior to everybody else?)

The WORST way to produce low cost health care is to hand it over to the government. You may get low cost, but if you do, it will be EXTREMELY low quality. Think DMV.

Besides, as the author clearly pointed out, socialized medicine has been an unmitigated failure everywhere it has been tried. He even gives stats to back up his claim Socialized medicine sucks. Even Michael Moore knows this. (But who wants to watch a movie about how much better the American medical system is than any other country? You might just as well check out a PBS special from your local library. Boring!)

Unsustainable costs
Kill private health care? The system we have is unsustainable. We do have to replace it with something. And at any rate, I don't recall there being anything in the Constitution that requires the government to guarantee the right of private companies to prosper in perpetuity. So let's replace them with a better, more affordable system from which only the citizens of the Republic prosper.

"Ever hear of "guaranteed issue"? Obama's first step in a government takeover of healthcare is an insurance law that already appears in states like New York and Massachusetts. Guaranteed issue means insurers must cover anybody who wants to buy health insurance—regardless of their health status. That means people who chose not to buy insurance, but got sick, can then turn around and get insurance after the fact."

I'll want to see a reference on that. I think "guaranteed issue" means that anyone, even those with pre-existing conditions, can get on board with the new national plan. At least that has been the commonly accepted definition up til now.

National health care works fine in every nation around the globe. We are the only nation that excludes such a large proportion of the population from affordable, comprehensive coverage. And curiously, we also enjoy the privilege of having the highest per-capita healthcare costs. With only middling results for those who can get coverage.

With so much having gone so wrong for so long, who could oppose taking a fresh look at the issue?

Next, "Insurance premiums in states with guaranteed issue are the highest in the United States. For instance, New Jersey's average monthly premium for an individual was $468 per month in 2007—that's twice the national average."

This one's tricky. New Jersey's state expenditures for health are very high-- just over $50,000 per capita. But expenditures in terms of the GSP (gross state product) are very low, 11.8% of GSP. All that says is that incomes in New Jersey are very high relative to the other states.

But if you look at how health care costs have risen over the past eight years relative to the increase in incomes, New Jersey's costs have increased by 4.7 times.. while in Maine, for example, it has been a 5.4-fold increase. In both states (and all the others as well) the increase in private healthcare costs relative to incomes is unsustainable.

Play around with this site:

http://www.familiesusa.org/resources/publications/reports/premiums-vs-paychecks-2008.html

In short, this article is in the best TCS tradition of advocacy journalism. The only question remaining is, which for-profit healthcare organization was the one funding the article?

We have no competition in health care.
Where competition exists, costs drop and quality improves.

Lasik is a great example and now we have clinics opening in CVS and Wal Mart stores as well as $4 prescriptions.

Allow insurance companies to compete across state lines, give the same tax breaks (or end corporate health cost tax breaks) to individuals and allow small businesses to join insurance pools.

Bottom line, free markets have not had a chance with the current government regulated system.

Now a shortage exists with family practice doctors as they are essentially in a regulated, third party system(socialized). Will the federal government force doctors be family doctors? Will they force people into medical school as more students seek more lucrative careers?

And the reason health costs and education costs rise is they are subsidized by the government.

Electronics and computer costs drop and quality improves. They are not subsidized.

Roy & Obamunism At Work
"And at any rate, I don't recall there being anything in the Constitution that requires the government to guarantee the right of private companies to prosper in perpetuity"

Where does it say that the People have a government right to health care, either? Amazing how you cherry pick that what you like in the Constitution that isn't even there. Oh, and while you're at it, show me where it grants the right to trial lawyers to prosper in perpetuity from medical lawsuits too.

"So let's replace them with a better, more affordable system from which only the citizens of the Republic prosper."

Simple, we get rid of the ridiculous special-interest mandates (like requiring men to pay for coverage with maternity coverage in it) that state governments like to heap on and thus jack up the costs.

"I'll want to see a reference on that. I think "guaranteed issue" means that anyone, even those with pre-existing conditions, can get on board with the new national plan. At least that has been the commonly accepted definition up til now"

Once again, Roy demonstrates to the world that he just doesn't know what the hell he's talking about. The reference is to state mandates like those in Massachusetts and refers to private coverage. THAT is the commonly accepted definition as of now.

"National health care works fine in every nation around the globe."

Prove it! Prove that it will be 'fine' for Americans who don't expect to wait 18 months for a hip replacement as well.

"We are the only nation that excludes such a large proportion of the population from affordable, comprehensive coverage."

Yeah, because we don't let the market determine what that health coverage available is so people can afford it.

"This one's tricky. New Jersey's state expenditures for health are very high-- just over $50,000 per capita. But expenditures in terms of the GSP (gross state product) are very low, 11.8% of GSP. All that says is that incomes in New Jersey are very high relative to the other states."

No it doesn't! JUST ONCE, stop the bulls--t Roy! What does ANY of what you just described have to do with New Jersey's average premium being TWICE the national average? NOTHING.

"In both states (and all the others as well) the increase in private healthcare costs relative to incomes is unsustainable."

THAT has nothing to do with this discussion. It has to do with overall affordability, not relative differences of 'over priced'. And, it is the fault of each of those states that keep heaping unsustainable policy coverage mandates. Which will STILL be there, Roy...unless ObamaCare provides only bare-bones coverage that doesn't have to meet state mandates. If that is the case, that only proves the point that private coverage could be easily more affordable if it didn't have to meet those mandates either.

"...which for-profit healthcare organization was the one funding the article?"

ALL health care provision is 'for profit', Roy! As long as the doctors are private and not forced into some Roy/Soviet Collective, that will always be the case. And even if they were forced to work like slaves, people would pay them under the table to get better care -- as they do in every socialized medicine nation on the globe that you and Michael Moore so cherish and love enough to hypocritically inflict on the rest of us.

unsustainable costs
You said that "national health care works fine in every nation of the world". Anybody who hasn't been on Mars for the past century knows that isn't true. Rationing and limited or old line drugs is now working fine. Indeed, I was just listening to a Swedish guy saying how even there they have rationing. He said that almost everthing in their hospitals and most of their drugs come from......the more competitive US. They, and much of the world are just free-loading on the States.
ITMT, try to find out why so many Canadians(including many politicians)go down to the States for treatment. Get a clue!

Shell game
What I don't understand is why so many are more concerned about the cost of medical 'insurance' than the actual costs of the products and services.

Sounds like a huge scam being perpetrated by the doctors, drug companies, medical products and the FDA and their affiliates and lobbyists.

It would be interesting to compare veterinary medicine and pet insurance with their human equivalents.

Since I don't have pets how does pet insurance compare? What is the competition? How is the service?

I was raised on a dairy farm and my dad trusted our vet over his medical doctor. He even had more effective medicine for ringworm.

If medical costs were competitive and reduced, real insurance (vs maintenance) would be lower as would maintenance care.

Anyone know why the issue isn't the cost of care and products?

Lifeline Screening
"Complete Wellness & Heart Rhythm Package + 3 blood
8 tests including 4 for stroke and vascular disease, 3 blood tests for heart disease and diabetes risk factors and 1 bone density screening for osteoporosis.
starting at $219."
http://www.lifelinescreening.com/screeningservices/Pages/PricingandDiscounts.aspx

I don't work for these guys, but I think they are are a great example of what can be done with free market medical care.

Of course the conventional medical community doesn't recommend these services.

BS Roy, utter BS.
National Health Care sucks Roy. I have lived in the UK, it is a joke. Those that could afforded private plans got good private care. Those that didn't suffered. I paid cash, I got excellent care while I went to the front of the line.

You have no clue. Where does it work Roy? How about nationalizing cell phones huh? Why stop with health care? Hell nationalize everything Roy. Energy,the works. After all, since government is non-profit it must be cheaper right? I wonder why it costs more then?

How about making private insurance a national market and allowing people to form pools? Huh? How about higher deductables as a option Roy? How about taking the insurance out of state regulation? How about private business pools?

You just don't get it, how does this make me more Free? I just cannot understand why everything with you is a government program.

Maybe Obama can tell me how to wipe me a** next huh?

Another Example
Laser corrective eye surgery, generally NOT paid by insurance-so there is as free a market as there can be in medicine.

Price down, efficacy-including reduced side effects-up.

One of my employees just had this done. Took Friday off, missed no other time.

Better than Slovenia
This is more like a rant than a well reasoned argument. Most people find national health care in the other developed countries to be both competent and affordable.

Competent? The WHO, for example, ranks US health care 37th in the world.. above Slovenia, but below places like Costa Rica, Chile, Morocco or Saudi Arabia:

http://www.photius.com/rankings/healthranks.html

Affordable? The one place where we do rank Number One is in costs. We have the most expensive health care on earth. And that is because there is no system in place. Everyone gets to charge market rates, and get rich servicing the top echelon who can afford expensive insurance.

Health care here is profoundly broken. The first thing I would do would be to combine all the pools, so those in the highest risk category (those already sick and broke) had access to care.

I would certainly not be opposed, if bottom-rung health care were comprehensive and covered catastrophic care, to having an upper-echelon. Anyone who wanted a gilt-edged policy, to cover convalescence in a luxury resort, could pay extra.

But if you come down with one of the bad cancers, or get paralyzed in a car wreck (two very expensive conditions) I don't think your care should be limited to how much savings you have in the bank. Because most of us don't have hundreds of thousands in cash readily available.

Finally, look how our health care of last resort works now. The poor go to the ER, where they get half-assed care from overstressed city hospital emoployees, for which they pay nothing. Then the cost gets passed on in the form of higher bills to everyone else.

A superior system? I don't think so.

Public health outcomes
I hate to disagree with the findings of some Swedish guy, but there are organizations that evaluate health services, and compare the total public health picture in all countries.

Let's look at Canada first.

>A 2007 review of all studies comparing health outcomes in Canada and the U.S., in a Canadian peer-reviewed medical journal, found that "health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent."

http://en.wikipedia.org/wiki/Canadian_and_American_health_care_systems_compared

They find the US to be #1 in responsiveness, for sure. And I suspect this is what you value most. Those who can afford first-class care can get it. But in average lifespan, child mortality and other categories, we're not that hot.

In fact we're in 37th place, behind countries like Colombia, Greece, Morocco and Saudi Arabia:

http://www.photius.com/rankings/healthranks.html

We're #1 in another category, of course. By far we're the most expensive place on earth to be sick or injured. An ordinary stay in the hospital can hit $100,000 in a heartbeat.

I would easily suspect many Canadians come to the US to get services they can afford that are better here. They are balanced by the millions who go the other way, to buy affordable prescription drugs.

Running a sensible health care program
Let's start with something we can agree on. Maternity costs are astronomical, and most doctors even refuse to deliver a baby now, because of the high risk of malpractise lawsuits. We all pay through the nose for the need for health providers to carry such coverage.

It's an area in need of reform. Where there is actual, demonstrable malpractise there should certainly be a means of redress. But as things stand, this is one more place where America needs fixing.

Now let's cover an area where we disagree: the definition of "guaranteed issue" health insurance.

I hate to disagree with someone who presents himself as being the infallible authority on everything. But if you'll take the trouble to google "guaranteed issue health insurance", and read the first 100 articles, I think you'll find that without exception they all define it as meaning that no one can be declined.. for pre-existing conditions, for age or for any other reason.

Next, you require that I "prove" that national health care is working fine for every other nation around the globe.

"Proof" is one of your words, it's not one of mine. You can't prove anything is absolutely true or false outside of mathematics. In the real world, things get all sticky. But I can offer some evidence:

The US is 37th among nations in the quality of the health care it delivers. But then again, look at Albania.. 55th. Tsk tsk.

http://www.photius.com/rankings/healthranks.html

As for your comment that all health care is "for profit", it's not. Explain nonprofits like Blue Cross Blue Shield. They are required not to post profits.. although I'll grant you, the guidelines have been much abused.

In France (the very first nation on earth for the overall quality of its health care) everyone gets affordable, high quality service. And the doctors get paid. Most of them fall short of $100,000 in income every year.. but somehow they manage. And you don't hear a lot of grumbling on the part of French doctors. Most of them offer the opinion that they're glad they don't have to run an office with a billing department able to handle twenty different ways to pay, or pay astronomical malpractise insurance and pass the cists along to their patients.

For them, life is simple. Just give the best care they know how to give. At the end of the month they get their paycheck. And much the same is the case for every other nation that's way ahead of us.

BTW you should see the Michael Moore film "Sicko". It would open your eyes if there was any way they could be opened.

Efficiencies of design
"Where competition exists, costs drop and quality improves."

The United States now has the most competition in health care provision on earth. And it is also by far the most expensive.

"And the reason health costs and education costs rise is they are subsidized by the government."

If they weren't, half the population would find health care unaffordable here. The other half could pay cash and get very good care. But if the government both paid for AND regulated costs, the astronomical costs here would come back into line with the rest of the world.

"Electronics and computer costs drop and quality improves."

Nope. In our system there are dozens of different payers, each with their own guidelines, exclusions and caveats. Every doctor in the country has to hire a billing secretary to try to keep things straightened out. This adds a huge chunk of change right there to our costs.

Then again, every payer also has to maintain a central office with a huge staff, processing claims. Add another chunk of change.

In France (number one nation on earth for the quality of its health care) there's none of that. The patient pays about a flat ten bucks at the door. The doctor then submits a bill to the government, who pays the rest.

Everyone in the country enjoys the savings in cost this system generates.

Question
What country did all this happen in?

If it was the US, are you aware that we are the only advanced nation on earth NOT to have national health care?

If you had two doctors participating in "bonus" programs, isn't that kind of thing the hallmark of healthcare in this country? Under a national plan there would be no bonus programs.

I fail to see how this could get any worse under a well run national plan. It would be eliminated.

All doctors work for profit...or you better wish they do
"I hate to disagree with someone who presents himself as being the infallible authority on everything. But if you'll take the trouble to google "guaranteed issue health insurance", and read the first 100 articles, I think you'll find that without exception they all define it as meaning that no one can be declined.. for pre-existing conditions, for age or for any other reason."

Uhhh...WHERE did I say that WASN'T the defnintion? No where. Please READ, Roy.

We were talking about how it was used in context for destroying the private health care system -- as was described in this article but YOU commented that you didn't get it. The Obamunists want to force private insurers to provide it but not require everyone to get it. This will bankrupt them....which is the Plan all along as the author points out. If you want to take exception to this point of the author's, fine. But you aren't.

"The US is 37th among nations in the quality of the health care it delivers. But then again, look at Albania.. 55th. Tsk tsk."

Really? Then why are people swarming to the US for treatment they can't get back home, eh? Why are Canadian doctors moving south of the border? Why does Michael Moore say that Cuba has the best health care system in the world when that is a total lie?

"As for your comment that all health care is "for profit", it's not. Explain nonprofits like Blue Cross Blue Shield."

Once again, you throw red herrings out there. The doctors work for themselves. Blue Cross is an insurer. And 'profit' in the context you make is only that they can't distribute it to investors. That is all 'non-profit' means. It doesn't mean that they don't make profit. The doctors are the providers and THEY work for a profit, either directly or indirectly.

"In France (the very first nation on earth for the overall quality of its health care) everyone gets affordable, high quality service."

Really? And France also has special medical courts to take malpractice suits to. No jury. That won't fly here in America. Therefore, their system would not work since a major part of their cost controls are by keeping the lawyers at bay.

"And the doctors get paid. Most of them fall short of $100,000 in income every year.. but somehow they manage. And you don't hear a lot of grumbling on the part of French doctors."

That's funny! Because every article I've ever read about France's 'system' has included a at least a token *****-session for the French doctors who are underpaid. Oh, and I don't like going to a doctor who is underpaid any more than I like taking my car in to a mechanic who is underpaid, do you?

"For them, life is simple. Just give the best care they know how to give. At the end of the month they get their paycheck. And much the same is the case for every other nation that's way ahead of us."

Fine...then MOVE there and PAY THOSE TAXES. Meanwhile, the rest of us don't want to join your little idea of paradise nor do we want be forced to.

Michael Moore is bald-faced liar and propagandist. And since you give him ANY credibility, you are guilty of the same by association.

Most Doctors (Roy Idiot Alert)
Don't deliver babies because they aren't OB-GYN's.

Nice to see provide your admission of hanging out in the echo chamber with Moore.

Perhaps you should give money to morthy worthy causes, rather than a man whose corpulence suggests a life of excess & conspicuous consumption.

WHO is anti-American
"Competent? The WHO, for example, ranks US health care 37th in the world.. above Slovenia, but below places like Costa Rica, Chile, Morocco or Saudi Arabia:"

WHO, like all UN agencies, is thoroughly anti-American and packed with many communists to boot.

Their stats are agenda driven.

"Health care here is profoundly broken"

Yes, in that we are all in agreement I think. What we don't agree on is your (and Obama's) attempts to use that as an excuse to make it far, far worse.

"The poor go to the ER, where they get half-assed care from overstressed city hospital emoployees, for which they pay nothing. Then the cost gets passed on in the form of higher bills to everyone else."

Yeah, because government messed things up with the mandates forcing hospitals to treat people who can't pay. So, you propose making things BETTER by having the same government mess things up further by getting involved further?


Non-profit (Roy Ignorance Altert)
Non profit is the misnomer of a status that allows exemption from federal tax and the absence of shareholders.

I assure you "non-profit" is not their business objective.



What are you talking about, Roy?
"If it was the US, are you aware that we are the only advanced nation on earth NOT to have national health care?"

Yes we do: Medicare.

And it is hopelessly mismanaged and going broke as well. And you want ALL Americans under national health care managed by the same morons?

And I was nice right there actually. I didn't bring up the oh-so wonderful track record of the VA hospitals.

Failure to See
>"I fail to see how this could get any worse under a well run national plan."

Right. And when that "well run" national plan turns out to be a "poorly run" national plan just like all the other budget sucking fiasco's in all these other "advanced nations", then what? Are we going to pull the plug on the monster simply because it is poorly run, over budget, and under performing? If it were that simple, Medicaid would be dead right now.

I work for the government, along with a lot of intelligent, hard working, competent people that I respect very much. But that does not mean that I suffer from the illusion that government programs are "well run". They aren't. They don't have to be. They are either monopolies, or they are subsidized with taxpayer dollars in order to compete. But "well run"? No. And the bigger they are, the harder it is to run them well. National health care would be a behemoth.

Instead of asking "What is everybody else afraid of?" perhaps you should ask yourself this simple question: "Why do I fail to see what everybody else apparently sees?"

You say you fail to see how it could get worse under a national plan? Did you read the article? Did you somehow miss the entire section about the wait times in Canada, Britain, and elsewhere?

Here, let me point it out to you:

"In Britain, people wait 11 months for a hip operation. In Canada, the mean waiting time for psychiatric care is 18.6 weeks, 56 days for an MRI, 17.6 weeks for surgery."

Are these "well run" programs in danger of having their funding cut? Are they in danger of losing market share to the "competition"? I don't thinks so.

Still "fail to see how this could get any worse"?

If so, it's not because you haven't been shown. It's because you simply choose not to see.

BS alert: "The United States now has the most competition in health care provision on earth."
How can that be when the government, the the insurance companies and the AMA control the market?

Governments regulate medical licensing and medical school certifications by doctor controlled state boards (no conflict of interest there!)

Government prevents insurance companies from operating across state lines. A company like BAE in Nasua, NH has to have different plans for their employees in NH and MA. Companies that operate across the country have to multiple systems.

FDA controls all medical products.

Where is the competition?

The WHO Criteria
WHO's criteria for ranking health care around the world is largely based on a criteria of AVAILABILITY, not QUALITY. The fact that lefties like to bring up the WHO designation as "proof" that other countries have "better" health care than the U.S. is based on a complete crock. While countries like Costa Rica and other Third Worlders indeed provide health care on a more "egalitarian" basis, that care it is in no way equivalent to the QUALITY of care here in the U.S., which is indeed the best overall quality available. What's the old line? "Lies, damn lies and statistics."

You'd do well to read this book: "Top Ten Myths of American Health Care"
http://liberty.pacificresearch.org/publications/the-top-ten-myths-of-american-health-care-a-citizens-guide

But of course you won't because it doesn't support your agenda.

Quality or availability?
It would probably be safe to say that Americans making over $50,000 had access to better health care than people making an average wage in a low-income country. But that's not the same as saying our system is better. It just means that only those who can afford, get. Because our health care is damnably expensive, and not affordable to all.

If you look at the health care available to the bottom third of our population, it is certainly worse than that for the bottom third of most other countries. Because they've made the decision that government should serve the needs of all their people, not just the rich ones.

There are only four countries on earth that don't have comprehensive national health insurance. That would be the US, Zimbabwe, Fiji and I forget the fourth. It's not a good list to be on.

My agenda is simply that a responsive government owes it to everyone of its citizens to care for them when they are unable to care for themselves. Those occasions are when you're too old to work, too sick or injured to work or when you're thrown out of work.

In that sentiment I'm in line with a majority of the American people. You're not. Nonetheless I urge that you continue to vote your feelings on the issue. Let's see the story the numbers tell, in 2010, 2012 and beyond.

Poor get free health care now.
All they need to is go to an emergency room. Federal law mandates they must be treated regardless of ability to pay.

Medical tourists
"Then why are people swarming to the US for treatment they can't get back home, eh?"

I'm not sure Canadians are "swarming" for treatment in the US. Certainly there must be some who come here, for things they can't get in Canada. But there are also US citizens coming into Canada for treatment, because it costs less.

In fact medical tourism is a flourishing business in many countries, due to high cost in the US. Brazil, India and Thailand are particularly hot destinations for medical procedures.

http://en.wikipedia.org/wiki/Medical_tourism

Next, here's our dialog on profit vs.nonprofit:

Me: "...which for-profit healthcare organization was the one funding the article?"

Z: "ALL health care provision is 'for profit', Roy!"

In that context, isn't it disingenuous to continue to proclaim that health care providers are all for profit? Individual doctors all work for personal oncome. But some health care providers are for-profit while others are nonprofit organizations. Therefore all health care provision is not for profit.

All you're doing is just trying to be disagreeable.

Then there's this: "Why does Michael Moore say that Cuba has the best health care system in the world when that is a total lie?"

I've seen the movie; apparently you have not. He didn't say that. What he did was to find a number of people who had been excluded from getting necessary treatments in the US by the terms of their policies.

Then he took them to Cuba and docked the boat. He asked the authorities if they could get treatment there. And at a very nominal cost they all did.. despite the fact that they were neither Cuban citizens or residents in Cuba.

His point was that they received better treatment in a very poor country with a very good medical plan than they did in the world's richest nation, with a bad plan. Nothing more, nothing less.

Pulling a stunt like this may fall under the definition of propaganda. But it is decidedly not a lie. His boatload of medical refugees did get treated in Cuban clinics.

But then, what do I know?
You say most doctors "Don't deliver babies because they aren't OB-GYN's." Not so.

My son's a small town general practitioner. He'd love to be able to deliver babies, and his patients would all like him to, rather than have to go to an expensive hospital up in Raleigh. And there really isn't all that much to it. You have to be prepared for adverse complications, is all.

But he can't. Malpractise insurance. Prohibitive.

As for nonprofits, they operate within very real limitations. They can't post a profit.. ever.

They can build up operating reserves. And often these reserves become substantial. But moneys can only be paid out for expenses. And if they routinely post what appear to be exorbitant and unnecessary levels of carryover reserves they can be challenged by the attorney general or the department of insurance, in the states where they operate.

They may be required to reduce the premiums they require of their members. That's a stricture you won't find in a for-profit company, one that pays taxes.

The one thing they can do that they shouldn't is to pay their top executives ridiculous salaries out of income from dues. But then, no set of guidelines is perfect.

Another thing would be to provide free services or funds outside the parameters of their charter. An example would be the naming of a sports stadium with funds dedicated to the health costs of the membership, or the funding of a free clinic for the indigent. In such cases it would be up to the members to initiate a class-action suit against the nonprofit, for failure to obey the terms of the charter.

Not exactly
The poor get bottom rung health care in this country. Go to the ER of a busy city hospital and you'll see.

They get one-time treatment for emergency conditions. No followup, no preventive care, not much of anything. They get stitched up and put back on the street.

Also, they get put out with a bill. It may not be a very large bill. But they do owe for treatment. What happens is that many or most are indigent, and can't pay. And there are many who won't pay. It's very common for people who know the system to show up with no ID. They then give fictitious manes and addresses. They have to be treated. And they don't pay.

We pay.

It's inefficient and far more expensive than if these people had more comprehensive coverage. Poor people get no care during pregnancy, for example. So they have more adverse, life-threatening deliveries. Not only is it worse for the mother, such short-sighted policies cost us many times more than decent maternity care would.

Why nationalize the medical system if the problem is the legal system?
Let's take your claim at face value. The reason your son won't deliver babies is because the malpractice insurance is too high. OK, so the next question seems obvious. Why is malpractice insurance so high for delivering babies, and how would socialized medicine fix this?

You hold up the French system as a model we should emulate. The French solution appears to be to reduce malpractice insurance costs by effectively eliminating malpractice suits. If a government doctor kills your baby, a government judge decides how much money you should get, and the case is closed. Is this really what we want? Perhaps it would be an improvement, I don't know. But even if it is what we want, why would we need to nationalize the medical system? Shouldn't you be arguing to reform the legal system, if that is the root of the problem here?

Most politicians are lawyers.
New amendment: Due to conflict of interest, no lawyer can hold public office.

Not Even Close (Roy Ignorance Aert)
Poor people get no care during pregnancy, for example. So they have more adverse, life-threatening deliveries.


Roy is right about one thing, there are more “adverse, life-threatening” deliveries, but not for lack of care. This is typical of a Roy fantasy- a comforting cliché to the leftist ideologues and one that begs to be disputed, since it is factually untrue and posited by an individual completely devoid of real understanding of the matter at hand.

I know because I am a former auditor of MA (Medical Assistance) programs in my state, with recent experience.
My state was moving to mandatory managed care for the very reason Roy cited-to intercept the high proportion of high risk pregnancies in the MA population with the theory that adequate prenatal care and education (about proper health) would reduce “adverse” outcomes.

In my time auditing payments, the key thing was to substantiate the eligibility of the recipient for “services” and the existence of the disease or condition that is being submitted by the provider for reimbursement by MA.

As such, I literally reviewed thousands of claim and “encounter” forms to review medical notes. I also interviewed provider staff members involved in the delivery of care as a part of normal audit inquiries-there was a depressingly high number that indicated high risk behaviors. I saw the following in depressingly high numbers.

Teen Pregnancy (saw children as young as 13 giving birth and becoming pregnant)

Drug Use (lots of claim forms bore notes indicating regular use of drugs)

Alcohol Use (ditto)

VD/STD’s (whether AIDS, Chlamydia, Herpes, Gonorrhea or something else-all bad)

Missed Appointments (I can’t wait to hear how this is everybody’s fault but the patients)

So while you’re wife/sister/friend was peeing on a stick, confirming the results with the doctor, abstaining from alcohol, taking her prenatal vitamins, getting appropriate nutrition (adequate folic acid) charting every milestone, making every appointment… a great many of those folks were going about their normal routines, using drugs, partying hard and sleeping light, not going to the OB/GYN and basically not giving a rat’s *ss about their baby or themselves.

Quite frankly, given the “lifestyles” of many of the MA population, it’s a amazing that there are any substantial numbers of healthy, life births at all.




Poor service, lack of oversight
Hi Joanie,

You say "I can have my healthcare when I need it. I won't get put on some waiting list."

My wife and I have a very good health plan. And access to first class doctors. So she's been having a persistent GI problem and set up an appointment the other day with her GI specialist.

The date he gave her? February 9.

Delays have very little to do with whether a system is private or public. They have to do with how well plans are managed.. in this country, for instance, HMOs are plagued with delays. And also with the number of physicians available relative to patients. The US is not noticeably better or worse than other developed countries in that regard.

Another thing: whether a plan is public or private, it's only as good as the regulatory structure that oversees it. Things like this "bonus" plan are clearly abuses not in the public interest. Better oversight on the part of government would have prevented such abuses from flourishing.

Options
"With a national healthcare system, I wouldn't be allowed to make changes."

Joanie, there's absolutely no rule saying that this has to be so. That's just a presumption on your part.

The Medicare prescription drug plan is a good example. You've got so many options that a chief objection to the plan was that there were too many to think about.

Our own plan is privately run but state administered. They have offered options up the ying yang.

Most plans, whether public or private, offer ample opportunities to change your primary physician or other care provider.

Wrong Again
"As for nonprofits, they operate within very real limitations. They can't post a profit.. ever."

Yes they can and do all the time. The profits may not "inure" to the benefit of a shareholder.

Do you really want to get into a tax debate with a CPA? Just admit you don't know what you are talking about and move on. The rest of what you wrote about "reserves" is such crap its not even funny-and the idea of some publicity hound AG (without actuarial training) determining the adequacy of reserves is just stupid.

I suspect however, you're a masochist and enjoy attention, even if the rest of the board thinks you are an idiot.

What is your major malfunction?




Nothing to it..
"He'd love to be able to deliver babies, and his patients would all like him to, rather than have to go to an expensive hospital up in Raleigh. And there really isn't all that much to it. You have to be prepared for adverse complications, is all."

There's nothing to it if everything goes fine. If everything goes fine, then you don't need a doctor at all. Then again, I'd rather be prepared with a specialist.

THe reason people go to study OB-GYN is that having training an experience matters. Delivering babies is life and death-its not like being a completely deluded and totally ignorant dufus ranting on about taxes, money and accounting on the internet. You're innumerable screw-ups are correctable after the fact.

The direct answer to then, what do I know?
Not much, based upon your vacant screeds posted here.

Allowing unlicensed practitioners to operate
I see.. we have a proliferation of employer-provided health plans, private-pay plans, HMOs, prescription benefit plans, state-sponsored plans, Medicare and Medicaid.. but that's not enough.

What we really need is to open up the medical profession to unlicensed operators. If we want ree-al discount medicine, let's let people put up their shingles without requiring the AMA to get involved. If things get slow in your line of business you can just set yourself up as a discount proctologist.

I swear. Every time I start thinking someday you'll start making sense, you have another setback.

The malpractise insurance issue
Jo, we're not talking about "the" problem, as though there were only one problem in the area of all medicine. There are many problems Each have many possible solutions.. and hopefully their own one, best solution.

Let's start with medical malpractise. I don't know where you got the idea there are no malpractise lawsuits in France. Just google "france medical malpractise" and you'll see this area of the law is alive and well there.

The malpractise problem is complex and thorny. Yes, we ned some recourse when things go wrong and the question of fault arises. But no, every adverse outcome doesn't need to go to a jury that's inclined to think the insurance companies can readily pay million dollar settlements each time, and everyone wins.

There needs to be some happy medium.

Note: this comment on one single aspect of our health care system does not imply any solution in other areas.

For what it's worth, there's no such thing as simple "socialised" medicine. This site..

http://en.wikipedia.org/wiki/Canadian_and_American_health_care_systems_compared

..estimates that in Canada health care is 70% government funded and 30% privately funded. While in the US, 45% is paid for by federal or state funding and the remainder by private funding.

Complex problems don't have simple answers.

Where is the competition?
The only real completion in the medical field are those services not paid for by third parties, like Lasik and boob jobs.

These services are expanding with quality improving and costs dropping.

Wal Mart and CVS are opening clinics in their stores. The mayor of Boston doesn't want to allow CVS to do. Don't know why.


Listening to the experts
I'm always willing to listen to an actual expert. But your info isn't looking all that good. I'm wondering, in fact, how you keep your job with stuff like your understanding of liquidity. And now, nonprofit reserve funds.

Here's an article called CRITERIA FOR NONPROFITS' OPERATING RESERVES:

DEFINED
Operating reserves or unrestricted fund balances are similar to retained earnings or owners' equity in business enterprises. They are funds, usually accumulated over several years, which are available for use by the organization at the discretion of the board of directors (i.e., net unrestricted money).

PURPOSE
Nonprofit organizations must maintain the balance between operating income and expenses in order to survive. Achieving this balance year after year is a considerable challenge due to fickle funders, economic uncertainties, etc.

etcetera.

http://www.iknow.org/pages/articles/criteria.html

If a nonprofit books an actual profit it has to pay taxes on the money so designated. But they don't have to. They can add to reserves.

What someone might consider "profits" in fact have to stay within the company and, as you say, not inure to the benefit of any shareholder. But that makes them no longer profits in any meaningful sense. They become operating reserves.. because NO ONE PROFITS FROM THEM.

If you'd like to learn more, here's a good tutorial:

http://www.duhaime.org/LegalDictionary/N/Nonprofit.aspx



Maternity practise
Maybe I should have added for the overly literal-minded that there's "nothing to it" for a competent GP who keeps up with his ongoing education.

The overwhelming majority of deliveries go without a hitch.. and the kinds of hitches that can occur in a "normal" delivery can be well attended in the context of a small town clinic. So all a good GP needs to know is how to assess the pregnancy and see whether there are indicators pointing toward complications.

If there are, he refers the patient to a maternity ward he feels he can recommend. And if, during a routine delivery, something unforeseen happens, he stabilizes the patient and calls for backup. That's the way things are (or used to be) done out in rural America.. and outcomes are not terribly worse than they are in a top rated hospital.

The complicating factor today is the astronomical rates for malpractise insurance for doctors-- all of them-- who deliver babies. It has made the practise of good medicine more difficult and less affordable.

Meicare and Medicaid increase costs
"On the demand side, the problem is simply this: The government pays for about half the health care purchased in this country, through the national health insurance for the poor and elderly known as Medicaid and Medicare. In 1990 ft state and federal governments spent $280 billion on health care. The costs of these programs have exploded over the years. Since Medicaid and Medicare patients pay little or nothing for health care, they demand more of it than they would otherwise. They have no need to shop for the best value or to be prudent about elective procedures.

All of this puts tremendous upward pressure on prices, harming everyone who pays for his own care. Until 1983, Medicaid and Medicare reimbursed health-care providers on a cost-plus basis, meaning that neither patients nor providers had incentives to keep costs down. This escalated prices, which, in turn, pushed up premiums for health insurance. The government-paperwork costs alone help raise the price of medical care for everyone. As a result, many people and small businesses are priced out of the insurance market. Mandated coverage by the states for such uninsurable things as hairpieces and in vitro fertilization aggravates that process. "

"On the supply side, various governmental regulations enacted at the behest of the medical profession have constricted the supply of doctors and other health-care professionals. Medical licensing and the power to accredit medical schools were explicitly motivated by the medical profession's wish to reduce competition and to increase the remaining practitioners' incomes. Between 1910 and 1920, when accreditation power was granted, the number of medical schools in the United States dropped from 131 to 85. The cut particularly harmed women and minorities; by 1944 the number of medical schools which predominantly admitted blacks fell from seven to two. Thanks to government, the medical industry is far less competitive than it would be if left free of interference. "

"If the government did not dominate the health-care industry through its humongous "insurance" programs, costs would fall to the reasonable levels we would expect of a free market. That would enable even the lowest-income people to buy medical care and health insurance. (To the extent governmental tax policy distorts the private insurance industry, costs would fall even further.)

On the supply side, the repeal of medical licensing, governmental accreditation of medical schools, and restrictions on hospital construction would increase the amount of care available, lowering prices even more. This would expand individual liberty and introduce real competition into the medical marketplace. Quality assurance would be much better handled in the free market through private certification organizations, such as Underwriters Laboratory and Consumer Reports. "

http://www.fff.org/freedom/0692c.asp

It has only gotten worse since 1992 and none of the free market suggestions described have even been tried. I wonder why?

Not looking good,looking stupid
Roy, there's a difference between a licensed (and to practice before the IRS-you must be a lawyer, A CPA or an enrolled agent) and a crackpot on the internet furiously searching out something from non authoritative sources, who can't evaluate their verity, utility or authority.

What you think doesn't matter. I answer you because I hope Joanie and a few others might see in you, a hoax and a charlatan-eager to regurgitate the blither gleened from echo chanbers, etc and grow to detest that which you are drunk on.

I get my info from years of study, of having passed the rigorous CPA exam and complying with continuing professional ed requirements. Moreover, I consult the code and regulations, not nonauthoritative websites that, if you quote accurately have confused "profit" with "unrelated business income" (don't worry about the difference, its beyond you)

You are the economic equivalent of a self-medicator, PREVENTION magazine in hand, arguing with the physician about your cancer being curable by macrobiotics.

Most people, even if they shoot off their mouth, know when they are beaten. You apparently fantasize about being a pinata. While it may not be charitable-the rest of us will be happy to keep swinging.



Very informative comment
From the title of your comment, I was getting ready to assume it was just more of your negativity and sour temper. But surprise! You actually make some interesting observations, based on experience. So I guess there's hope.

First, to get this out of the way, my experience of bottom-rung health care comes from working the streets of DC, in the inner city. And any HC provider there will tell you the same things I've told you.

Whenever I had a vacant house on the poor side of town, for example, I'd find a stack of mail having been delivered that invariably included a handful of ER bills and ambulance bills, made out to names that never lived at that address. Half would come in pink, past due envelopes. So yes, the billing scam was universal, and satisfied two needs.. the need for the service provider to try to get some kind of payment for services, and the need for the recipient to not have to pay anything. Billing was a polite formality.

So who paid? It turns out that the major HC insurors have all worked out pay scales with the hospitals that keep their bills pretty low. That leaves only the guy with no clout at all.. the individual who pays cash.

Hospital visits, for the person paying cash, run a good 40% higher than they need be, on average, because they include compensation for all the bums who get free care. If you'd like to check that, you can compare average billings for some given procedure, whether paid through an HC provider or paid by the patient. Those numbers are readily available.

To me, not a good system. But that's the one we have.

Onward, to your own observations on prenatal patients, they're all right on target. That's because they're reality based (as are mine) and not just some idea someone's thought up because it fits his world view.

I hope you provide us with more of the same. The fact of your residence in Massachusetts, for example, goes a long way toward explaining your hostility toward anything that looks like socialism.

Having Actually Examined Maternity Claims and having an RN Wife..
You don't always know in advance there's going to be a problem. The fact that "The overwhelming majority of deliveries go without a hitch", is a meaningless statistic if your bably is in distress. Better the delivery is handled by a specialist from the beginning, with the appropriate equipment and support teams ready to go. I have two relatives alive today, because everything was fine-until it wasn't and there was a well versed obstetrical team that spang into action, preventing in one case, fetal hypoxia or perhaps fatal asphyxia.


"The complicating factor today is the astronomical rates for malpractise insurance for doctors-- all of them-- who deliver babies. It has made the practise of good medicine more difficult and less affordable."

Lets not forget who the trial lawyers own, lock stock & barrel.


Why exactly are you so argumentative? Are you that desperate for negative attention? Its not only that you lack financial acumen, you can't seem to make a sound argument on anything.



Sorry
I find your endorsement a matter for concern.

I'd rather be sour and accurate than verbose and uninformed like you.

Boy, are you in a bad mood
Supe, I know you can't be having fun doing this. And the arguments you choose to make fail to convince. So why on earth do you persist?

I used the word "liquidity" where you might have used "insolvency".. loosely but properly. And I pointed out the case in which the use of "liquidity" would even be preferable. But you can't just accept that and move on. You have something inside you that absolutely refuses to accept that I'm not "proven" wrong.

And, having run out of more proof, you don't even try to provide any, you're just frothing at the mouth in this latest riposte.

I have freely admitted that on occasion my terminology is loose, even inappropriate. And I stand to be corrected whenever that's in order. I've never studied, as you have, to be a CPA. And I dont have at my fingertips that entire body of specialized knowledge.

But I have a working knowledge of what that's about, because I've worked closely with CPAs, comptrollers and the like over the years.

When I discuss business with any one of them, we continue with the discussion until they're satisfied that I understand the concepts involved. But that's not the object with you. All you want to do is to try to find some ***** in the armor you can work on, to see if you can widen it into some point only you can score.

It's sad, pathetic and a misuse of your talents. Get a life. All we're doing here is discussing issues. And your insistence that I have misapplied a single word serves no useful purpose.

For the record, I have not. I will stand by my initial comment, that we're going through a liquidity crisis. You are also correct, that it is in some degree a crisis of actual solvency. But I think that those in the know would admit that the money is there (although so much has been foolishly spent on bum investments), it's just that those who have it are reluctant to lend it out.

If you'd like to disagree, and offer evidence that the money on deposit has actually disappeared, I'd be interested in hearing your argument.

Argument for its own sake
"Why exactly are you so argumentative? Are you that desperate for negative attention? Its not only that you lack financial acumen, you can't seem to make a sound argument on anything."

I frequently have something to add to the discussion. And almost invariably, it seems to be at odds with what everyone else has to say. So in the interests of a diversity of opinion (not to mention, of fact) I add my two cents.

This only becomes argumentation if someone else chooses to try to find some way to oppose it.. and continues opposing it to the death.

In asserting that there are doctors whose clientele would like them to deliver their babies, but the cost of malpractise insurance makes that prohibitive, I offer the testimony of my son, the doctor.

He's an old time country doc. People go to him because he's good and they can afford him. If he doesn't deliver their babies they have to go into some tank town like Smithfield, to find a hospital with an obstetrician. And I concur with them, that Ted's as good or better than anyone they'll find in a place like that.

I will also offer that in my opinion, he's not the sort to volunteer for something where later he'll find he's in over his head. The guy enjoys a very good reputation in the profession.

Is all this argumentative? Only if you tell me your opinion of my son is more accurate than either mine or his own.

Even in victory, grousing
Whenever you have a point, I'd be glad to award you that point. Would that you could learn to be as charitable.

I do prefer it when you speak from actual experience, as opposed to getting on a high horse and preaching. It sheds more light, and propels the discussion forward.

Adding Futility
"I frequently have something to add to the discussion. And almost invariably, it seems to be at odds with what everyone else has to say."

What you frequently have to say is almost invariably wrong. Continually positing the economic equivalent of the sky is red, the earth is flat, the moon is made of green cheese isn't adding something to the discussion, its futile and stupid. You seem eager to demonstrate manifest ignorance, especially where economics is concerned, corrected-like on the whole matter of nonprofits.

I have no opinion on your son, I don't know him. I don't form opinions of people I've never met-unlike you, who think I'm from Massachusetts. At least there's one licensed specialist you'll defer to on technical matters you lack training on.

What I know is that I have two relatives that are alive and healthy because their arrival was directed by OB-GYN's, who had the benefit of specialized training, experience, staff and whiz-bang equipment that was summoned as soon as said obstetrician said "stat". I believe in "safety first". If its my kin, I'll vote for the OB-GYN, rather than a "old time country doctor", just as I'd take the OTC doctor over a midwife.

Any woman over 35 having her first is AUTOMATICALLY diagnosed as have "elderly primigravida". (Old first pregnancy). Look it up-it automatically triggers a higher level of prenatal scrutiny. With more women postponing pregnancy until their 30's, a greater amount of preganancies are NOT routine for that simple fact alone.





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