The CEO of the Mayo Clinic, Dr. Noseworthy, was last heard recommending patients fire their physicians suffering from burnout. While he does not have truckloads of compassion or empathy for colleagues; he is, at least, honest. Dr. Noseworthy recently confessed “We’re asking…if the patient has commercial insurance, or they’re Medicaid or Medicare patients and they’re equal that we prioritize the commercial insured patients enough so… We can be financially strong at the end of the year to continue to advance our mission.” The ‘ailing’ nonprofit generated a paltry $475 million last year.
During his speech, Noseworthy noted the “tipping point” was the recent 3.7% surge in Medicaid patients as a direct result of ACA Medicaid expansion. “If we don’t grow the commercially insured patients, we won’t have income at the end of the year to pay our staff, pay the pensions, and so on,” he said. These are difficult decisions to make by rationing access to healthcare for the poor. It is a moral dilemma those of us in independent practices have been facing for some time.
Mayo will continue taking all patients, regardless of pay or source, and this policy exempts those seeking emergency care.
This move is attempting to shift payer mix and mitigate the financial pressure faced by many health systems as a result of federal health-care reform. Approximately 50% of patients at Mayo Clinic are Medicare or Medicaid. Higher reimbursements for privately insured patients makes up for losses incurred treating Medicare and Medicaid patients. Mayo says these payers reimburse at about 50-85% when compared to commercial insurance. It is about the same in my office.
While ACA Medicaid expansion brought the reality of healthcare coverage to millions; it left behind the practicality of providing access to healthcare for those same millions. As a direct result of the ACA, demand for physicians now overwhelms supply, due to increased closure of independent practices from incentivizing hospital consolidation. Physicians are not mean or spiteful, but we have families to feed, mortgages to pay, office rent, employee salaries, malpractice insurance premiums, and last but not least, student loans payments hanging over our heads. If my office closes, access further declines.
Throwing millions of additional patients onto Medicaid worsened the quality of care for those who were already on the program pre-ACA. Four years ago, my payer mix was 50% Medicaid and while never flush with cash, I was able to survive. Post-ACA, the payer mix must shift to 75% commercial and no more than 25% can be Medicaid in order to mitigate financial pressures. I have been closed to new Medicaid patients for more than a year with more than 70 families on the wait list.
Prior to The ACA, America rationed costs by not covering a portion of the population for preventive services yet mandating provision of emergency care (EMTALA) to everyone in spite of operating at a financial loss. Our post-ACA healthcare model still rations care by a variety of mechanisms: price, (copays, deductibles, premiums), capacity (physician shortages, advent of independent midlevel providers, certificate of need for facilities), and utilization management limitations (prior authorizations, referrals.)
Healthcare has remained a beautiful construct yet dysfunctional machine. Pricing measures reward error, inefficiency, and poor outcomes, private and public sectors continue to have a love/hate relationship regarding unbalanced cost shifting, and ultimately, attempts to regulate this catastrophic system by the government will lead to worsened outcomes for the poor across the board.
The American Health Care Act (AHCA) is not perfect, but it is pragmatic. Limited by the budget reconciliation rules to fast-track for Senate consideration, it was designed to attain 218 votes in the house and 51 votes in the Senate, which will generate cheers as well as jeers on both sides of the aisle. The bill is an important first step toward compromise and away from the disastrous ACA.
The AHCA would significantly expand health savings accounts, allowing patients to control more of their own health-care dollars, and give those who buy coverage on their own considerably more choice in the kinds of plans they buy. This change alone will allow lowering of premiums. Its refundable tax credit will be available to low- to moderate-income individuals and will equalize the tax treatment of employer and individual insurance.
The bill would transform Medicaid into a more streamlined insurance program: moving decision-making to the states, permitting them flexibility in dealing with preexisting conditions, provide reinsurance, and trust state insurance regulators to run their markets. In my opinion, not providing enough assistance to the poor and elderly is a fly in the ointment, however this can be adjusted in the next round, making premiums more affordable for the poor.
The AMA and the AHA oppose this plan; the importance of which must not be overlooked. These organizations do not represent practicing physicians and have very little interest in supporting the physician-patient relationship. It is very encouraging to me neither organization was able to garner much in the way of concessions on their behalf.
When the AMA and the AHA speak out against a bill, one must consider the AHCA as likely to be beneficial for both patients and physicians in the long run. Less than 15% of physicians today belong to the AMA and they pad their pockets by burdening practicing doctors with excessive regulations. The AMA receives $72 million from licensing the ICD-10 coding system, a restrictive noose around our necks which increases costs of running a practice.
The AHA states they will collectively lose $166 billion dollars if the ACA is repealed. It is worthwhile looking at who profited most from Medicaid expansion. Patients theoretically stood to benefit from improved coverage, but only when access was coupled with coverage, which it was not. Of the $3 trillion dollars spent on health care, hospital care accounted for 32% ($1 trillion), while one-fourth of those costs ($250 billion) accounts for salaries and benefits of hospital executives. The annual average hospital CEO salary is $600,000, while the average primary care physician makes $185,000 (for the record, I have never even come close to this amount.) Physicians receive only 8 cents of every healthcare dollar spent. Do any of those expenditures appear to be benefitting patients? Obviously, the answer is no.
The AHCA is a very good start, like 100 lawyers at the bottom of the ocean. It does not seem like much at first, however over time, it will make a positive difference. Anything is better than the ACA for patients, physicians, and our sacred physician-patient relationship. When you delve further into the details of the AHCA, you will find less coverage on the surface, yet more access for the people. It is time to take the power away from the AMA and the AHA and build a healthcare plan that is pragmatic; knowing there is no perfect and only compromise, but that is something of which we are in desperate need.
Categories: Uncategorized
“but I think someone with 80k for 6 person household can afford to pay some healthcare costs, for example a $5 copay.”
Hard for me to disagree right now. I do get frustrated at low income people having more babies, but am in favor of free birth control (not supported by the right generally) and some type of financial counseling/oversight of tax money spent by recipients. That oversight may be something state HHS does, I don’t know. I am going to check with my state HHS.
The number of children could have been a result of better economic times, can’t say, as each case would be different. Good Catholics have as many children as they can.
It’s so interesting. If you read my next post, Dr. Smith goes to Washington, commenters are saying congress members shouldn’t have to meet physician constituents unless we are same party or have donated $. No wonder healthcare is such a mess.
I get that number from my patients who say “I must keep our income below x amount to have Medicaid coverage, so I can’t work.” It’s 50k for a family of 4. 65k family of 5, and 80k for family of 6. I’m not saying these numbers are inappropriate but I think someone with 80k for 6 person household can afford to pay some healthcare costs, for example a $5 copay.
Yes Niran I know you’d make more money, what I asked is would it allow you to see more patients and cut the “rationing”?
Niran, it seems Peter’s big thing in life is to place the blame on physicians. Physicians don’t pass legislation nor are they an enforcement agency, but he expects them to be the government’s eyes and ears. I don’t even think he understands our limitations involved in the release of information said at the bedside.
Where are you getting that number from? My state of NC has a family of 4 with dependent children income limit of $744 per month.
For infants and children family of 5 looks to be $5037 ages 0-5, and 6-18 $3190. But I’m not sure about how the mixed ages would work out.
Pregnant women are different.
“Your resources may not be more than $2,000 for an individual or $3,000 for a couple. The value of your home, a car, home furnishing, clothing and jewelry are not counted.
Resources include:
Cash
Bank accounts
Retirement accounts
Stocks and bonds
Cash value of life insurance policies
Other investments”
Not sure how “rich” this makes Medicaid recipients. It aligns about with 138% of Federal Poverty levels. The $5037/mth for family of 5 seems high on the surface but 5 people with kids take a lot of resources. I’ve never had children, but you’ll know better.
What income would you use to give Medicaid coverage?
Yes. totally and completely. I would LOVE to receive Medicare rate of reimbursement,. It would help independent pediatric practices survive.
Me too, Peter. I have reported especially when they commit insurance fraud ie have private insurance, yet hiding it and do not tell us while “using” the Medicaid only. Sometimes I am not aware they have private insurance and figure it out once medicaid figures it out, they take back all the money they paid us and then we cannot bill insurance. I have a policy that anyone caught lying about insurance is kicked out and cannot return to my practice.
Peter, I am not certain they are committing fraud. The medicaid limit is quite high, above 65k in annual income depending on your family size. Regardless, they have more disposable income to spend than I do and that is again fine however no one is asking their subsidized care be taken, rather that they know the costs.
You are nitpicking again. The k in know how was missing. Your use of the words “meaningful discussion”has a new meaning. It means you don’t understand the subject matter.
Take a Valium Peter.
“Your poorly worded sentence above should have been ‘do you now how to manage expansion?”
Not sure what poorly worded “now how” means, is that an english term? Thought I’d better check since you choose to split hairs and avoid any meaningful discussion.
Say goodnight Allan.
Then you misunderstood what I said or you changed the context of the two words.
“there is no program that managed expansion.”
Do you know of a program that managed expansion appropriately? Your poorly worded sentence above should have been ‘do you now how to manage expansion?’ Your sentence made it look like a type of program such as managed Medicaid.
Some of the clinics I have seen love those patients, so the problem isn’t solved at all. What you have done is incentivized dishonesty.
“Is it a Peterism?”
No, it’s a direct quote from you. You used the term, I expect you’d know what it is and how it could be applied to Medicaid expansion.
“”I wouldn’t deal with patients that committed fraud and that is one reason I didn’t want to take Medicaid. I’ve had some try, but they were either stopped or released from my practice.”
Solved without bureaucracy.
I don’t believe “managed expansion” is something that is presently in use. It appears to be a made up phrase. Is it a Peterism?
To answer your question, Yes. I have gotten thank you’s, but no follow up and no change. I dealt with these bureaucratic problems all over the spectrum including working on a committee censuring physicians. The answer is bureaucrats do not make waves. It is not in their interest.
The government doesn’t seem intent upon rooting out fraud. See 60Billion dollars of Medicare fraud from 60 minutes 3 -5 years ago. That is the tip of the iceberg.
“Well if there are not enough people to check these problems, that’s not socialism, that’s just bad management.”
That is the nature of socialism and oversized bureaucracies.
“Do you know what % in your practice are committing fraud?”
I wouldn’t deal with patients that committed fraud and that is one reason I didn’t want to take Medicaid. I’ve had some try, but they were either stopped or released from my practice.
That was not my question. You seem to have an idea what managed expansion would look like, would like to know as you seem to have studied this.
“but from my experience these things aren’t pursued.”
So you’ve reported fraud several times and the cases have not been pursued? Did you followup?
“That is the problem with too much socialism. Eventually one runs out of other people’s money.”
Well if there are not enough people to check these problems, that’s not socialism, that’s just bad management. I don’t know what the case load and resources are.
Do you know what % in your practice are committing fraud?
Peter, there is no program that managed expansion. The ACA just dumped people in a wastebasket.
“Rates are just as low as they have always been, so rationing is the law of the land right now in our community.”
If you were paid Medicare rates for Medicaid patients would that cut the “rationing”?
Yes, Peter they are committing fraud, but from my experience these things aren’t pursued. It is very easy to stay under the radar and once on Medicaid and to manage finances in such a manner that the individual will remain on Medicaid even if they were investigated.
I know one person that drives a brand new Lincoln SUV, lives in a relatively expensive home, eats out a lot, goes on cruises, and other vacations, yet remains on Medicaid.
That is the problem with too much socialism. Eventually one runs out of other people’s money.
“It doesn’t do much good for the poor very needy ill Medicaid patient by adding ?14 million more patients without expansion of the program”
What would “expansion of the program” look like?
“It is true I have many families on Medicaid who drive expensive cars, have large homes, the moms get to stay home (which I will admit I am totally jealous of), and they travel to Mexico and Disneyland each year.”
Niran, if you suspect Medicaid fraud then you have a duty to report it. People who violate the income and asset limitations of their state are committing fraud.
Here is what you can do:
https://www.cms.gov/medicare-medicaid-coordination/fraud-prevention/fraudabuseforconsumers/report_fraud_and_suspected_fraud.html
Actually, Peter, I have few families on ACA plans through the marketplace. Almost 90% of those who benefitted through signing up on the exchange are on Medicaid known as Apple Health. Rates are just as low as they have always been, so rationing is the law of the land right now in our community. I am not angry the ACA didn’t solve problems, I am frustrated with a system worse than before.
Barry, it is probably due most to the poor payer mix and aging facility costs. I was born at the hospital that is closing. It is more than 50 years old. We are significantly underserved in my area and some will travel across the water by ferry to get better care. Micro hospitals could be an option but where to find the funds?
Peter, technically, my husband earned our Tricare after 20 years of service to this country in the Army Special Forces. I have never said people should not get subsidized care, Peter. Many people need help, but not necessarily by handout approach. I absolutely believe a standardized way of looking at income etc should be applied and then providing coverage on a sliding scale. I pay plenty out of pocket using our family Tricare and that is fine. Some cannot afford that, they should have equal coverage. Many of my insured patients however do not have the equal level of coverage as Medicaid despite paying far more in costs. The middle is being squeezed out of existence.
j, thank you for the support. It is true I have many families on Medicaid who drive expensive cars, have large homes, the moms get to stay home (which I will admit I am totally jealous of), and they travel to Mexico and Disneyland each year. I often wonder how they can be on Medicaid and still do all of those things. Then, on the other side, I have many Medicaid families struggling to make ends meet and I am so glad their children have a safety net. It is an intriguing idea to use the VA system to support the poor. It would provide the basic level of coverage I have always talked about.
Peter, those Peterisms are flying out of your keyboard again. I’m from the right on the more libertarian side which means I tend to have some agreement with both sides of the isle except the Democrats of today which have gone bananas and would probably crucify JFK.
I don’t know of many conservatives, if any, that wish to “take Medicaid away from the poor” or better said ‘care for the poor’, rather most are trying to see that the money is spent wisely and not just for show. It doesn’t do much good for the poor very needy ill Medicaid patient by adding ?14 million more patients without expansion of the program, but the left thinks it’s swell because the numbers look good even if the people are dying.
The left loves abstractions but seems to hate reality.
“You earned your Tricare, nothing to be ashamed about on that end..There are many bullies on the left that have not earned and just want to take.”
J, I was not questioning whether Niran “earned” her Tricare or not, just the fact that she is getting subsidized care while seeming to want those in ACA not to get subsidized care. Where do you get your subsidized care? The working family at a minimum wage job – did they not earn a subsidized policy through the ACA?
As for bullies on the left, it’s the right that wants to take Medicaid away from the poor and reduce those on ACA by 24 million +, while giving the “rich” yet another tax break. And I think defunding Planned Parenthood, which provides many health services to low income women, is the height of bullyness.
Given the ever widening gap of rich and poor I’d say the bullies are winning.
This whole administration is based on bully tactics.
Dr. Al-Agba, I really enjoyed your article. I think you are spot on and I see the world from a different, insurance company person’s perspective. You earned your Tricare, nothing to be ashamed about on that end..There are many bullies on the left that have not earned and just want to take. I agree our current system is set up for the rich and the poor, all of us in the middle have to ham and egg it. Go to Urgent care, fill up our HSAs, etc.
You can never control costs in healthcare because the current system forces to provide the same quality to all no matter how they got into the system. This is communistic and has failed every time its tried. My plan is to move all of our Veterans to the best blue cross plan money can buy and convert our current VA into a public health program for the poor and have it run along side of our independent private healthcare system.
The private system would be 100% private with insurance and almost no government regulation and the public system would be for everyone else who can’t afford to work and can’t obtain private insurance. I would cap the admission on the public plan at about 5% of our total population. The public system may not be as good as the private one, but oh well, in America, you should be able to pay and get better. Not pay, and wait in line or not be able to see a doctor because they have 100’s of Medicaid patients to see.
Believe it or not, there are a lot of people who scam the healthcare system subsidies and there are a lot of people on there who are not really ‘poor’. But if you can do it and get the same quality, why not? I know at least a few who have their kids on CHIP, who make plenty of money. Under the table. That’s the one thing the left never takes into account in their master entitlement plans. People will always look for others to pay for their health care first if they can. Those same people have great looking teeth because if Dental is not subsidized, they will pay for it themselves because it affects their looks. Maybe you can go back for a little school and become a dentist, most dentists do not have money problems.
Niran, is the hospital that’s closing shutting down because of an unsustainably low occupancy rate, a poor payer mix (too much Medicaid and uncompensated care), an inadequate case mix or some combination of all three?
It does seem that your area is significantly underserved in terms of hospital beds even before the closing. Are micro hospitals of 7-10 beds each an option, and if so, who would build and operate them?
We are (mostly the left) creating a monster that we are afraid to deal with. Every attempt government makes to deal with this monster is something that attempts to mimic a free market endeavor, but they fail because these ideas are based upon top down control.
Medications cannot cost more than people can afford. Pharmaceutical companies go bankrupt if their product is unaffordable. Look at the epi-pen. I have one for myself. The price was raised to $600+. The CEO who took a multimillion dollar salary increase had a father in Congress. Seldom is one person buying that api-pen. The insurer is actually paying for it and tags on a relatively small amount to each person in the pool to pay for that pen. My actual payment after Part D was around $74 so even I didn’t know there was a less expensive pen out there called Adrenaclick for I think $200. There are also syringes and epinephrine that costs almost nothing. We are being slowly boiled in water like the frog that doesn’t jump out.
“I want to provide care to as many patients as I can and keep a roof over my head. The ACA is not doing that.”
Well the ACA gave some of your patients a way to pay you above Medicaid rates or even charity care. That must help you and them.
Your problems with finding affordable insurance/coverage is the same as everyone else. Your angry that the ACA didn’t solve all your problems, well so are a lot of people, but U.S. health care the 5 star hotel of the world.
I’ve been through that as well and decided to go uninsured for a time with cash pay, no Tricare option for me.
Allen, you know I just gave a talk about Medicare Part D and ways to cut costs. A physician who owns a DPC practice on the East Coast was talking about a patient on Medicare paying $900+/mo for meds. DPC’s get their meds from Andameds for wholesale and then dispense them directly to patients. The cost after switching to generics and after this patient signed up with the DPC doc, $35/mo. Unbelievable how much difference a physician could make, huh? 🙂
You are right Big Pharma benefitted greatest from Medicare Part D in the long run.
I didn’t switch, the plans for small businesses (which I am) ended. The company “got out of the small business market” entirely. I gave up trying to find another plan after searching for something and fell back on Tricare. I take care of my own kids and rarely need much in the way of medical care, so it was easier than fighting a system working against the self-employed.
I am not really complaining about Tricare, it is the equivalent for us of catastrophic coverage, a little better. We rarely go through the individual deductible or family one either for that matter. Look, you can disagree with me, but at some point you should admit that I want to provide care to as many patients as I can and keep a roof over my head. The ACA is not doing that. Something needs to change. I do not have all the answers, but what we have is not working.
We have two/soon to be one hospital that will serve 250K. The main hospital (soon to close) has 250 beds but just had a legionella problem with the water system. The “newer” hospital which is about to combine with the older one hence the monopoly has 94 beds, 24 of which are NICU. The helipad is finally located at the hospital now, when I first started practicing in town it was a mile away at the local mall parking lot. By my calculations, minus the NICU beds, we are at about 1.3 beds per 1,000 population. I guess that puts it in perspective huh? Almost every specialist has been bought by the hospital so choice is gone. Three left that are independent in town, including me.
“has to reflect, at least to some extent, the values and culture of its society.”
That is why it is foolish for anyone to say we are the only western nation that doesn’t have national health insurance.
No, I’m not saying it’s a bad thing. Every country’s healthcare system has to reflect, at least to some extent, the values and culture of its society. Countries can learn from each other but just because the system in say, Sweden, works for them and the population is happy with it doesn’t mean it could be adopted here with similar results and satisfaction. At the same time, Germany copied Medicare’s DRG payment system for hospital based care after they had problems with their prior per diem approach.
Niran, it seems like we have quite a lot of doctors around here but I don’t have any numbers. We also have five hospitals in the county one of which has a top notch trauma center and can do sophisticated procedures like open heart surgery. Even our local community hospital which is 1.5 miles from my home has a helipad in the rear of the parking lot. I think the total number of inpatient beds for the five hospitals combined is in the range of the national average which is a bit under 3 per 1,000 of population or roughly 1,800 beds total.
Peter, the core of my practice was mostly middle to low income seniors that were among the sickest of the seniors and were on many medications. There were loads of medications that before Part D was passed that were very inexpensive and worked.
I remember when Hillary, during the Clinton administration, talked about this poor woman who had to spend $10,000 (I think) on medication and let us know why. I could have treated that woman for about $500 certainly less than $1,000 worth of medication.
Most of the newest medications I needed were offered for free or for $15 per month by the drug companies to poor patients. I gave other poor patients samples and tried to use medications that could be split.
Some of my patients needed additional help but we didn’t have to have 75% of Part D subsidized by the taxpayer plus an additional ~10% subsidized elsewhere. I’m being subsidized and I don’t need it. I do, however, pay at a higher level for Part D. If we are using taxpayer funding, the funding should be carefully targeted and monitored. We do none of those things and impoverish poor working families. We will pay for this when those children grow up without being appropriately cared for by their parents.
When Part D was being sold I nicknamed it the Merck Bailout Act. Merck was in trouble and without sufficient new meds in the pipeline. Part D created a floor and I believe preserved Merck’s pricing. It did nothing to the ceiling except incentivize higher pharmaceutical prices.
“Americans just wouldn’t accept it.”
Are you saying that is a bad thing? We don’t accept dictatorship either.
Almost every doctor I dealt with has quit. I won’t say they retired because they had planned to retire a bit later. Adding up the number of physicians, the years of practice lost and the experience we can calculate the millions of dollars (maybe a lot more) wasted at a time that many feel there is a doctors shortage. These were the guys that used to see their patients in the ER (didn’t use hospitalists), worked until all the patients seen, worked seven days a week and were efficient.
So why did you switch from individual to ACA? The ACA was not forced on you, you just needed coverage by somebody.
Your description of premiums, co-pays, deductibles is what non subsidy ACA patients are complaining about. Yes, the cost of care in this country is outrageous, but why should we control system costs by always wanting to control the other guy’s access to care and subsidies?
I have been looking up Tricare, it sounds like subsidized insurance, maybe like ACA, only better.
Of course, this will be our future if we continue to move toward a universal system. The poor will either get lucky or not. Those who can afford it will go outside the public system into the private one. Personally, fewer complications the better my outcome…. I would go private in that system.
Look, I had insurance in the individual market until the ACA went into effect. Tricare was secondary to that. It was about $900 for my family of 5 with a high deductible. I do actually know what I am talking about. Through AHCA If a family of 5 was receiving $10k in tax credit and they purchased a high deductible plan (hopefully costs would come down to $500/mo) then that leaves 4K in the HSA to use for expenses. If one wanted to contract with a DPC, at $150/mo per family (average most places in the US), then it costs $1800/year) for unlimited care visits. Done. Cheaper, Better. If they need catastrophic, then they use it, but 80% or more of chronic issues can be managed in a DPC practice. I am in no sanctuary. I am in a county which is slowly becoming a medical wasteland. People need physicians and they are not going to be here much longer.
MACRA is legislation that basically wants to control how we practice, paying only for “value” which has never been studied to validate. It insists upon EHR usage and adds thousands of dollars to costs for my office which cannot afford the transition. It will be the last nail in the coffin for many independents if we are not exempted.
The supply of NP’s is not great either. I have interviewed many of them and they want no less than 100K annually. I sometimes make that and sometimes don’t, so I cannot guarantee that amount to them. You are correct they are not a replacement, but in light of NO care, it would make sense. Some of the family docs can afford that, I can’t at this time. it is less of a burden if they are employed by a hospital, but again they charge facility fees to offset the cost and bring in enough revenue. I am forbidden from doing that.
Yes, 250K sounds like a lot of people. It is about 600 square miles also, but it is poor and geographically isolated by water, so the more physicians we lose, the worse off the population. Currently, there are 8 orthopedists, 3 general surgeons, and 14 pediatricians. Interested in the numbers from your area as a comparison. Thanks.
PartD was Bush’s deal with the drug companies to keep their prices, profits, and lobbying support, and attempt to help seniors busing to Canada for affordable drugs. I cancelled my membership to AARP when PartD past, they lobbied hard for it. Rep. Billy Tauzin made a million dollars in a lobbying job from it, you can see his smiling face and the check on the internet. But how would you have solved drug pricing in the “free market” so seniors could afford it?
If you want the “free market” to control old age health care who could afford it? Tell me who? Young people in the individual market with no subsidy can’t afford it. If you want a comparison – what would a $100K life insurance policy cost to a 26 year old and a 65 year old?
By the way, no one forces you to sign up for Medicare. You could just buy a private policy.
And what do you think the individual market would cost you out side of Tricare? Because that’s what you’re trying to solve, what everyone is trying to solve, the cost of care/insurance in the individual market – too many are casting solutions from the sanctuary of their own subsidized plans.
Barry, thanks for furthering our information about Australian healthcare. Lines are a big problem for socialist healthcare systems. Therefore when comparing the US to others one has to include the cost the socialist line.
The grass always appears greener on the other side, but here in America the grass is about as green as it comes.