Sarah-palinFormer Alaska Governor Sarah Palin’s widely publicized comments on death panels and  rationing this August were among the opening shots of an unprecedented national fight over health care reform. At the time, few sober analysts would have predicted that Palin’s criticisms would gain traction. Yet, they found a receptive audience among conservative opponents of the Obama administration’s health care reform plans, triggering an ugly battle between supporters of reform and right wing opponents.This weekend, Gov. Palin returned to the healthcare debate with another post to her official Facebook page that touches on the talking points you’re likely to hear in the months to come from Republican critics of the Obama administration’s health care reform efforts.  In the spirit of debate we are republishing the post in its entirety. — John Irvine

Now that the Senate Finance Committee has approved its health care bill, it’s a good time to step back and  take a look at the long term consequences should its provisions be enacted into law.

The bill prohibits insurance companies from refusing coverage to people with pre-existing conditions and from charging sick people higher premiums. [1] It attempts to offset the costs this will impose on insurance companies by requiring everyone to purchase coverage, which in theory would expand the pool of paying policy holders.

However, the maximum fine for those who refuse to purchase health insurance is $750. [2] Even factoring in government subsidies, the cost of purchasing a plan is much more than $750. The result: many people, especially the young and healthy, will simply not buy coverage, choosing to pay the fine instead. They’ll wait until they’re sick to buy health insurance, confident in the knowledge that insurance companies can’t deny them coverage. Such a scenario is a perfect storm for increasing the cost of health care and creating an unsustainable mandate program.

Those driving this plan no doubt have good intentions, but good intentions aren’t enough. There were good intentions behind the drive to increase home ownership for lower-income Americans, but forcing financial institutions to give loans to people who couldn’t afford them had terrible unintended consequences. We all felt those consequences during the financial collapse last year. Unintended consequences always result from top-down big government plans like the current health care proposals, and we can’t afford to ignore that fact again.

Supposedly the Senate Finance bill will be paid for by cutting Medicare by nearly half a trillion dollars and by taxing the so-called “Cadillac” health care plans enjoyed by many union members. The plan will also impose heavy taxes on insurers, pharmaceutical companies, medical device companies, and clinical labs. [3] The result of all of these taxes is clear. As Douglas Holtz-Eakin noted in the Wall Street Journal, these new taxes “will be passed on to consumers by either directly raising insurance premiums, or by fueling higher health-care costs that inevitably lead to higher premiums.” [4] Unfortunately, it will lead to lower wages too, as employees will have to sacrifice a greater percentage of their paychecks to cover these higher premiums. [5] In other words, if the Democrats succeed in overhauling health care, we’ll all bear the costs. The Senate Finance bill is effectively a middle class tax increase, and as Holtz-Eakin points out, according to the Joint Committee on Taxation those making less than $200,000 will be hit hardest. [6] With our country’s debt and deficits growing at an alarming rate, many of us can’t help but wonder how we can afford a new trillion dollar entitlement program. The president has promised that he won’t sign a health care bill if it “adds even one dime to our deficit over the next decade.” [7] But his administration also promised that his nearly trillion dollar stimulus plan would keep the unemployment rate below 8%. [8] Last month, our unemployment rate was 9.8%, the highest it’s been in 26 years. [9] At first the current administration promised that the stimulus would save or create 3 to 4 million jobs. [10] Then they declared that it created 1 million jobs, but the stimulus reports released this week showed that a mere 30,083 jobs have been created, while nearly 3.4 million jobs have been lost since the stimulus was passed. [11] Should we believe the administration’s claims about health care when their promises have proven so unreliable about the stimulus?

In January 2008, presidential candidate Obama promised not to negotiate behind closed doors with health care lobbyists. In fact, he committed to “broadcasting those negotiations on C-SPAN so that the American people can see what the choices are. Because part of what we have to do is enlist the American people in this process. And overcoming the special interests and the lobbyists…” [12] However, last February, after serving only a few weeks in office, President Obama met privately at the White House with health care industry executives and lobbyists. [13]

Yesterday, POLITICO reported that aides to President Obama and Democrat Senator Max Baucus met with corporate lobbyists in April to help “set in motion a multimillion-dollar advertising campaign, primarily financed by industry groups, that has played a key role in bolstering public support for health care reform.” [14] Needless to say, their negotiations were not broadcast on C-SPAN for the American people to see.

Presidential candidate Obama also promised that he would not “sign any nonemergency bill without giving the American public an opportunity to review and comment on the White House Web site for five days.” [15] PolitiFact reports that this promise has already been broken three times by the current administration. [16] We can only hope that it won’t be broken again with health care reform.

All of this certainly gives the appearance of politics-as-usual in Washington with no change in sight.

Americans want health care reform because we want affordable health care. We don’t need subsidies or a public option. We don’t need a nationalized health care industry. We need to reduce health care costs. But the Senate Finance plan will dramatically increase those costs, all the while ignoring common sense cost-saving measures like tort reform.

Though a Congressional Budget Office report confirmed that reforming medical malpractice and liability laws could save as much as $54 billion over the next ten years, tort reform is nowhere to be found in the Senate Finance bill. [17]

Here’s a novel idea. Instead of working contrary to the free market, let’s embrace the free market. Instead of going to war with certain private sector companies, let’s embrace real private-sector competition and allow consumers to purchase plans across state lines. Instead of taxing the so-called “Cadillac” plans that people get through their employers, let’s give individuals who purchase their own health care the same tax benefits we currently give employer-provided health care recipients. Instead of crippling Medicare, let’s reform it by providing recipients with vouchers so that they can purchase their own coverage.

Now is the time to make your voices heard before it’s too late. If we don’t fight for the market-oriented, patient-centered, and result-driven reform plan that we deserve, we’ll be left with the disastrous unintended consequences of the plans currently being cooked up in Washington.

- Sarah Palin

[1] See
[2] See
[3] See
[4] See
[5] See
[6] See
[7] See
[8] See
[9] See ibid.
[10] See
[11] See ibid.
[12] See and
[13] See
[14] See
[15] See
[16] See
[17] See

This post originally appeared on Sarah Palin’s official Facebook page.

73 Responses for “Good Intentions Aren’t Enough with Health Care Reform”

  1. Nate says:

    Dr. Weinstein broaches an interesting point. Right or wrong the physician/patient relationship is a holy one. I have to think a large part of maintaining this close working relatoinship is being able to use the insurance company as a fall guy. If a doctor discusses your options with you and it is the insurance company that says to try step therapy first or wait two weeks for an MRI they take the blame and provider remains the trust buddy. If you start asking doctors to factor cost into their treatments then patients will start to blame them, is this the road we want to go down?
    Personally I don’t think doctors should be making any judegments about the cost aspects of care. With only minor offense intended have you ever seen how poorly they run businesses? A doctor should make the patient aware of all treatment options in an unbias manner. It is then the responsibility of the patient, with consideration to what his insurance will reimburse, to decide which route they want to go. If the patient wants the expensive drug and is willing to pay the difference then the insurance company and doctor have no right to interfer.

  2. J Bean says:

    Medical transcription: Medical care is labor intensive and labor costs make up the bulk of the (non-administrative!!) costs. The average annual household income in India is $550 (US) while the average annual household income in the US is $55000. It’s actually kind of surprising that the US cost of medical care is only 10 times the cost of Indian care. That would imply that Indian care is relatively expensive.
    MD as Hell: The US is not “bankrupt”. The US has a GDP that is only slightly smaller than the entire European Union. The national deficit has been proportionally higher in the past without any problem. There is one political party that makes a big fuss about “financial responsiblity” … whenever they are out of power (they borrow and spend like drunken sailors when they are in power).
    Numbers taken out of context are meaningless.

  3. A blog by a disgraced clown like this and 54 comments to boot?( I am stupid enough to be #55)
    This is surely one of Matt’s jokes?- right?
    If not-THCB- You have hit a new low for you
    Dr. Rick Lippin

  4. MD as HELL says:

    J Bean,
    We are no longer loaning money to ourselves. Soon we will be owned by our creditors. We will have to stop sometime. Now is good.

  5. Andrew Weinstein, MD says:

    Margalit Gur-Arie
    **Medicare is offering a 2% incentive to physicians for using electronic prescribing software,…**
    The response rate to this in particular, and the incentives to switch to EMR in general, is so low because the cost of implementation is greater than the incentive given. And though it does show options, it (and Medicare) do absolutely nothing to push toward cheaper but equivalent alternatives. Private insurance companies do. That was, and remains, my point. When people like Ram Duriseti assert that insurance companies bring nothing to the table, I feel compelled to respond.
    **What baffles me is that while stating that medicine cannot be reduced to a cookbook, you are perfectly OK with accepting intervention from a variety of cookbooks …**
    I am not and never said that I was. I am however OK with being asked to justify why I chose a $700/year drug as opposed to a $50/year drug. After all, I am spending their money. The ticklish part comes if/when they disagree with me and still refuse to cover the drug despite my explanation. Has happened twice in my career and one was ultimately reversed upon further appeal up the ladder. In the other the patient paid out of pocket for the more expensive drug. Again though, my point was that unlike Medicare, private insurance companies do make an effort to keep down the costs of healthcare in ways that do not adversely impact quality. Some insurance companies mail out letters reminding women to get mammograms. Does the federal govt (Medicare) do something as simple as that? No. So when people tell me that Medicare is “more efficient” than private payors, all I can do is laugh. I mean, they don’t have to collect the premium, they provide no disease management, they make no effort to question costly drug prescriptions or imaging studies. All they do is write a (small) check, one that is, in effect subsidized by private payors. But I digress.
    **Those cookbooks are solely based on cost analysis.**
    And outcome. And that’s all that should count: cost and outcome.
    **Do you get a call when you don’t order the MRI, and maybe you should have?**
    Errors of omission are always much more difficult to track. I don’t know of anyone capable of doing a decent job with that. It only comes under scrutiny when someone has a bad outcome through inaction.
    **Lastly, I don’t think that asking physicians to be more aware of the power they have on influencing health care costs is tantamount to full risk HMOs. **
    No, and perhaps I responded too strongly to that. It’s just that the current system is designed to reward overuse. The more I do the more I am paid. Full risk HMOs failed because they still linked compensation to consumption, or lack thereof. Until physician income is tied to outcome (a difficult and tricky thing to do) instead of utilization, there will be no significant change in physician behavior.

  6. J Bean says:

    MD as Hell:
    We need to acknowledge that there is actually a very low percentage of discretionary spending in the budget. Lowering the tax rate on the very wealthiest of Americans in 2001 resulted in going from a ~$500B budget surplus to a ~$1T deficit. We need to raise the upper marginal tax rate and reinstate the estate tax. The very wealthiest currently pay a smaller percentage of their income in taxes than those of us (that includes you and me, bub) in the middle. Paris Hilton needs to pay her fair share. In all likelihood, those of us at the upper end of the middle (that does include you and me) need to make a slightly higher contribution to Social Security withholding.

  7. Andrew Weinstein, MD says:

    **Personally I don’t think doctors should be making any judegments about the cost aspects of care.**
    It depends. If two treatment options are equivalent in outcome (generic ACEI vs branded ACEI for HTN or CHF) why should I not choose the less expensive one without offering the more expensive option to the patient. Where I agree with you is if the outcome is not equivalent and the difference in cost is large. It is not for me to judge whether a small benefit is “worth it”. Example: Plavix vs aspirin in patients with chronic CAD (not post PCI). The is an 8.7% relative risk reduction with plavix vs. aspirin over 5 years. So if the 5 year risk of MI, CVA or death is 20% on aspirin it is about 18% on Plavix. Is that absolute reduction of 2% over 5 years worth $1800 per year? That’s not for me to decide. If you earn $500,000/year you would probably pay it. If that $1800/year was the difference in being able to pay the mortgage or not, you probably wouldn’t pay it. In cases like this I will often inform the patient of the data and the cost and let them decide. The are several problems with this though. 1) It is VERY time consuming. 2) Many patients lack the statistical sophistication/education to really understand what I am telling them. They are therefore incapable of making an informed decision. 3) Much more commonly in medicine the difference in outcome between two different therapies is not really known. We may have reasons why we believe or think option A is better, but there is no data to support or thought one way or the other.

  8. rbar says:

    Apart from all the invectives (you are clearly distinguished in that category), I notice that you have only a pale idea of medical waste/overutilization. Most of it is not conscientously choosing a more costly option, but docs ordering unnecessary tests and treatments, often asked for, explicitely or between the lines, by the patient. I too would agree that a patient should be able to get the unnecessary MRI for migraines if he/she is willing to pay for it (or for supplementary insurance), but for the covered majority, there has to be a principle: you get what is proven to be clearly beneficial (or thought to be beneficial by experts), but for everything else, you have to pay.

  9. Nate says:

    rbar careful judgineg the entireity of ones knowlwedge by a couple hundred post.
    Asking for unnecessary tests and treatments is choosing the more costly option. Each treatment is a decision on its own, by choosing to have a test that is not needed or repetitive is more costly then choosing to forgo said treatment.
    I disagree with limiting people to what is clearly beneficial, I think more of our health is mental then medicine prefers to admit. Placebo’s do cure the perception of a condition, the perception of a condition can cost just as much or more then the actual condition. If rubbing cow urine on your hand relieves your arthritis and stops you from getting an Humira Rx then please apply generously. Not to mention there has been more then one case of medicine being wrong. Heard thinking can be dangerous, heard treating deadly.
    I also don’t see a difference between paying for beneficial treatment or paying for voodo medicine, we pay either way. If our systems where properly structured people would rarely get reimbursement from insurance, they would pay medical bills in lieu of premiums.
    From 20 years of paying doctors claim there is nothing I will ever be able to do to stop providers from delivering unnecessary care, only the patient can say no to a treatment so that responsibility must lie with them, I can educate and enform them but in the end they need to make the decision. Peter/Phillips don’t take that as an absolute and point out the couple exceptions where I can in fact deny treatment.
    Andrew I’m capitilist, if there is a more expensive option you would be a terrible businessman to not offer it. As a for profit effort your job is to sell your service, withholding your service becuase you don’t think it is worth it I disagree with. If some rich person wants to pay $100 per aspirin becuase they are hand pressed you should gladly take his money and reduce the cost of aspirin for average joes. A functioning economy requires the redistribution of wealth, I rather the wealthy spend their money then it be redistributed by a tax man. By selling designer cures health care companies can invest in research or subsidizing cheaper and new cures. If they are greddy bastards and keep all the extra money for profit that to is fine as that trickles down to mutual fund owners where are predomintly average people’s retirement accounts.

  10. Margalit Gur-Arie says:

    Wow, Nate! Wow! I have no idea where to start, so I won’t even try.
    I think you just illustrated why medicine is not, cannot, will not ever be the same as any other business.
    I am 100% certain that no self respecting physician practices this way, other than maybe some folks in places like McAllen….

  11. Andrew Weinstein, MD says:

    I’m a capitalist as well. But as a physician my role is to recommend that which is best for the patient, not that which is best for me. I routinely recommend a course of action that is not in my economic best interest.
    **I also don’t see a difference between paying for beneficial treatment or paying for voodo medicine, we pay either way. **
    Then you don’t see the difference between productive labor vs paying someone to dig a hole and then fill it up and there is little i can do to open your eyes. The point is to get maximum health care bang for the buck. Paying for ineffective treatment is not going to do it. But I suspect you know that and are simply being “provocative”.

  12. Nate says:

    I don’t think you can ever rely on an aultristic system, efficency is maintained by personal responsibility.
    productivity is measured by the person paying for it. If some person perceives benefit from hiring someone to dig a hole and fill it up repeatidly then the person doing the work is being productive. You might disagree with the value of a hole being dug and filled but you can’t deny the person doing the work was productive. They dug and filled a hole.
    While you are a good doctor that pratices in the best interest of your patient many doctors do not. You can’t build a system predicated on all doctors being honest. If you build a system based on the assumption doctors will pratice in their best interest you greatly reduce the inefficency of those that do not, a properly designed system wouldn’t impeed an honest doctor but would a dishonest one.
    Maximum ROI can only be achieved with a strong paying consumer. We have tried strong providers, strong insurance companies, and strong government and none of them lasted more then a decade or so.
    Isn’t a mechanis suppose to fix cars? Attorney’s represent their clients, Politicians represent the voters, you can’t rely on what other people are suppose to do.
    Margalit that was the way I feel it should work, not saying that is how it does work.

  13. With all the increased awareness of ghost-authoring practices in the medical community, I’m really surprised that THCB ran an article that was clearly not authored by Sarah Palin. When that is added to my general disapproval of this cookie-cutter, GOP-message-laden post (that provides no new information for anyone truly keeping up with the issue), THCB has just gone down a serious notch in my estimation.

  14. Bill Kolter says:

    Health care reform will create waiting lines for specialist care. This short video explains it very well. Check it out.

  15. Good intentions or not matters little, what we need is common sense and forthrightness in attacking the real problem and in the process being honest with the American people. None of that is happening now.
    What we are going to get is a good solution for the wrong problem with the creation of an even bigger problem down the road. About the time Medicare crashes, we will learn about the problem we have created with a new public option.
    And, the American people will learn what it really takes to control health care costs (as will the medical profession so willing to jump on board with the current version of problem solving.
    Here is an assessment you may want to take a look at.

  16. RC Goughnour says:

    Well the health care debate is alive and kicking.
    I am not sure the question about Ms. Palin’s daughter’s health care provider was ever answered and I don’t know for certain who paid for the expenses. However, my (very educated) guess is that the taxpayers did. Remember, Mrs. Palin’s husband is an Alaska Native. This entitles him and his children to “free” care from the Alaska Native Medical Center, part of the Indian Health Service. Now I suppose she could have also been covered under the State of Alaska’s health care program Mrs. Palin would have been covered under as Governor or the health insurance plan available to Mr. Palin as a BP Alaska employee.
    What is important to realize about the Palin family is that, even though Mrs. Palin quit her job and Mr. Palin quit his job, unlike most Americans, Ms. Palin’s children and husband were guaranteed free coverage under the Indian Health System. Which, by the way like the VA, Medicare and Medicaid charges back services provided to beneficiaries to private health plans. Therefore the Palin’s may still be mired a sink hole of “coordination of benefits” paperwork if the daughter was covered under both private and public plans. I would however doubt that their family is on the hook for paying those expenses out of pocket as most other American families would have been.
    This being said, most of the comments on this site (along with Mrs. Palin) are still not dealing with the real issue here. The real issue is: who and how will health care be paid for. As long as our society guarantees that everyone, no matter their ability to pay, will be provided health care services, there will be a mechanism for paying for that care. Reason also tells us that the answer to the question of who pays is “the citizens of the US.”
    So, we can waste time and energy arguing about secret meetings, who pays for Mrs. Palin’s grandchild’s health care or other irrelevant issues or we can cut through the “blue smoke and mirrors” (thanks Jimmy Breslin) and talk about the real issue; how do we structure a plan that is cost effective and provides quality care to all comers. Unfortunately, like the brouhaha about Mrs. Palin’s comments on “Death Panels”, we are easily sidetracked. There are some truths that must be faced in this debate. They are:
    1. The cost of providing health care services to residents in the US will come from the pockets of those same residents; be it through taxes, health insurance premiums or direct pay for services.
    2. Care will be rationed. Whether that is through an insurance company using formularies for prescription drugs or putting exclusions and limits on what they will pay for or a government agency “cutting reimbursements” nobody will get unlimited care unless they can pay out of their own pocket (another form of rationing.)
    What we do know about our current system is that it is inefficient because of COB, especially between government programs the private sector plans. These provisions make privately funded plans the payor of last resort. In my opinion, this is a tax on private plans (which are paid for out of the wages of employers and employees) and shifts the costs of government plans to the private sector. The same goes for “cost savings” plans which lower reimbursement for publicly funded plans such as Medicare and Tri Care. Providers who take these patients pass on unreimbursed expenses to (can you guess?) privately funded health insurance plans whose premiums go up as a result or people with or without health insurance who pay cash for services.
    So, let’s get the debate back on track. Here is my first suggestion; all plans that are funded through tax dollars should be prohibited from charging back private health plans. Congress should acknowledge the commitment they made to the beneficiaries of these programs and provide the funds necessary to pay for the promised services. This was the standard many years ago when private health plans had COB restrictions against paying for services provided to beneficiaries of government plans. In my opinion bringing back this provision would go a long way to eliminating much of the cost shifting from government to private insurers. Second, it would free up funds now being paid for claims administrators and allow it to be used for providing services to sick people.
    So, can we debate the real issues here or are we to continue the name calling and accusations of unethical behavior by public officials? Let’s hope we can get back on track a solve the quagmire we in the US call a “health care system.” We owe it to future generations to fix this mess.

  17. acai berry says:

    all plans that are funded through tax dollars should be prohibited from charging back private health plans. Congress should acknowledge the commitment they made to the beneficiaries of these programs and provide the funds necessary to pay for the promised services. This was the standard many years ago when private health plans had COB restrictions against paying for services provided to beneficiaries of government plans.

  18. R Quinn says:

    It’s not a matter of changing simple pieces of who has what incentive to do what, it is a fundamental change in the way be pay for health care and how we evaluate those who provide that care.
    For example, why do we have a system with hundreds of thousands of doctors acting like small business entrepreneurs?

  19. Mel Hawkins says:

    Governor Palin got one thing right, in her article on “Good Intentions,” when she said that “good intentions are not enough.” The problem with pending healthcare-reform legislation, like so many reform initiatives that have preceded it, is that it is not really healthcare-reform legislation, it is “health insurance” reform legislation.
    Until we are willing to admit that the problem with the American healthcare system is health insurance, we will continue to add new layers of complexity to a system that is already convoluted.
    Think about it for a moment. If our objective is to provide universal access to healthcare, what value do health insurance, managed care, Medicaid, and Medicare add? Don’t these entities exist to restrict access to care to only those individuals who are covered? Don’t these entities exist to limit care to only those services that are covered by an individual’s specific policy?
    If we are serious in our desire to make healthcare available to all Americans, we must eliminate the middlemen and then apply a little American ingenuity to reconstruct the system to do what we need it to do. The Reconstruct Healthcare Blog unveils a uniquely American solution to our healthcare dilemma while keeping government out of the healthcare-delivery business.

  20. demitr says:

    The Republican party got us into the heath care mess by blocking govt alternative….
    The single Payer health care does not cost a whole lot. Small business and individuals who want to could buy into the plan and it would break the monopoly on health care…
    The GNC or Republican party has a long history of lying and Sara Palin on on the lying band wagon.
    They lied about Iraq, weapons of mass destruction.
    They lied about it being a big mistake…
    Cost 1 trillion and counting.
    The lied and are lying about health care.
    Cost 15 trillion.
    Evidence: Blue/Cross holds monopolies in multiple states…. These blood sucking liars and their allies are funding Fox News and right winger Glen Beck who is right out of the 1950′s McCarthy Scare.
    Which is better the present corporate take over of health care where you have absolutely no say or government takeover where you have some say?
    Fact: In all of the so called Socialized Health care countries they could vote out socialized health care in one day and no country is doing that including Glen Becks “communist Australia, Canada and ofcourse Communist New Zealand and don’t forget Communist Great Britian.”
    Fact: In all of these countries the same drugs that you pay for here are ten times cheaper there.
    Fact: There are more doctors and nurses which drastically brings the costs of
    health care down while make their health care system 5 times better than ours because Doctors go to medical school there for free.
    (Life expectancy much higher and there they have the H1N1 vaccine for all, here
    you have to wait in line and we are getting the rationed heath vaccines.
    Fact: The ave wait time in the ER in the USA is 6 hours.
    Fact: the Ave wait time om the ER in France is less than one hour.
    Fact: Cancer patients are given “Standard medical treatments at the so called best hosptials in the world while the most effective treatments are barred from
    the USA by Big Pharma and it’s Cohort The FDA to insure Big Phama get it’s the biggest profit.
    Fact: Diabetics will become the no 1. killer in the USA while Burger King and Big Mac keep their junk food profits going.

  21. Gary Lampman says:

    Caribou Barbie (Shara Palin) Has become the Image of the Party of No.Turning back time to ownership of humans(slavery), women as mere property and the masses as indentured servants. Just Like O’sama Bin Laden is the face on the War on Terror.She is Cute, comes in several poses and matching outfits. She, like all Barbies loves MR Ken. Who still is a Bachelor. Why that is so? The GOP needs Caribou Barbie to be distraction from the Ugliness that engulfs the party. I think Ken and Barbie who were only plastic Figures. Need to stay out of Health Insurance Debate.
    I also feel that Health Insurance companies are Unnecessary and any Doctor worth his weight needs NO GUIDANCE by insurance.The reason Medicare is so unappealing is the returns are smaller.However, the demographic that uses Medicare frequents providers on more frequently.
    The Bottom line; Its Just the Money!!!!
    I wonder; if other services like Auto Mechanics,Electricians, Heating and Air were set up the same way,requiring insurance as a prerequisite to provide Services.Would it only be a privilege of affordability or a basic right?

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