Health care crisis needs reform, not more government

By Senator Jeff Kruse

In general terms, it seems to be commonly accepted that we are in a “health care crisis.” Admittedly, our system is broken and in need of major reform, but I reject putting a crisis label on health care. My reason is very simple. By calling anything a crisis one is calling for government intervention to solve the problem and in health care government is more the cause of the problem than it is a solution. We only need to look at history to understand the point. Health care used to be a free market system with no government involvement (pre 1960’s) and it worked relatively well. Presidents Johnson and Nixon changed the dynamic forever with Medicare and Medicaid. With all of the advantages one can argue we have seen from these programs, the fact is government involvement and regulation have been the biggest factors in the ever escalating costs of the system. Health care may be the most regulated system in our country. From insurance mandates to determination of covered services, a conservative estimate of the cost of government required paper work is over 30% of the health care dollar. Next time you go to your doctor look at how many people there are in the office not dealing directly with patients and you will start to get an understand of the scope of this problem.

Many who choose to call this a crisis envision government solutions. No matter what label they try to put on this movement it still comes down to the government take over of the health care system. Maybe it is time to take a hard look at an existing government system, and I choose our neighbor to the north, Canada. Clearly, the Canadian system does a better job of getting people in the door for a checkup or to diagnose a healthcare problem, but from there the system falls short. If, for example, it is determined you need an operation, you may have to wait in line a significant amount of time, as the system only allows for so many procedures a year. While insurance premiums in Canada may be only around $100 per month, most working Canadians are in a 50% plus tax bracket to pay for the system indirectly. As we watch both the Canadian and British health care systems imploding upon themselves it is becoming increasingly clear government is not the solution.

I have spent several years working with a wide variety of people trying to fix the Oregon Health Plan and for the most part those efforts have failed. I opposed Measure 50 in this last election primarily because it was just another attempt to put a small bandage on a large wound. I also opposed Senate Bill 329 (which passed) because it set up a series of work groups to study various aspects of the health care system (most of which have already been studied) but still pointing to government solutions.

I did support, and was a sponsor of Governor Kitzhaber’s proposed Senate Bill 27, (which did not pass) because it proposed taking a fresh look at the entire system. Clearly Medicaid and Medicare will continue to be a significant part of healthcare. However, we should be willing to critically investigate how these programs work as I am certain, we can do a better job of expending the existing billions of dollars a year in our budget.

So what is the solution? It is not an easy question to answer, but to find a solution we need to start from a new place. The concept of free healthcare quickly becomes unaffordable and a system run and regulated by a third party tends to be unresponsive. We need to move back to a system where medical decisions are made by the doctor and patient.

We need to look toward models like, Health Savings Accounts where the individual has a financial stake in their own healthcare. If we truly want people to move toward preventative health care they need to have a financial stake in the results, and if we want health insurance to be affordable we need to once again make it a simple major medical plan.

In a Health Savings Account type system a person’s day to day medical needs would be paid directly out of their individual account and if a serious event occurred it would be covered by insurance. This system will work well in both the private sector and the public sector. Additionally, if we could get the flexibility in Medicaid and Medicare expenditures envisioned in Senate Bill 27, we could achieve further healthcare success.

Clearly, this is just the tip of the iceberg in the continuing discussion of healthcare reform. We also need to be looking at issues such as the lack of providers and tort reform to name just two. We need a health care system that is affordable, accessible and most importantly understandable. These should not be buzz words, but the actual goal we are striving for. I will continue to be committed to this effort.

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  • Steve Buckstein

    Senator Kruse makes many good points here. I wlll, however, question one. SB27 would have included Medicare in the discussion of an overall health care reform package, which by itself is probably a good thing.

    The bad part of SB27 is that it would have sent the message that its author, former governor Kitzhaber, was on the right reform track. He was not. He has diagnosed much of what ails the current health care system right, noting that employer provided health insurance, Medicaid and Medicare are all failed systems, but his cure may be worse than the disease.

    Kitzhaber points to the public school system as his model for a new health care system. He points out that every child is guaranteed a K-12 public education and we simply fight over how much tax money will be collected and spent to make good on that guarantee. There is little consumer choice in the system except for those financially able to pay the taxes and private tuition too. Politics rations the school books, teachers in the classroom, and everything else in the public education system, and cost control goes out the window. Accountability to the customers – students and their families – goes out the window also.

    Modeling health care after public education will quickly lead to rationing by government, not budgeting by consumers. Costs will go up, not down, just as they have in Kitzhaber’s earlier mini version of health care reform, the Oregon Health Plan for Medicaid recipients. Why we should push all Oregonians into such a system before we get the smaller one right is a question worth asking.

    • Margaret Goodwin

      I wouldn’t model anything on the public school system. (Not even the public school system.)

      SB27 notwithstanding, I agree with most of what Senator Kruse states in this article. Healthcare may be broken, but turning it over to the government won’t fix it. Adding more layers of bureaucracy rarely makes anything cheaper. Traditionally, the private sector has proven to be more efficient, and to provide higher quality services, than the government, largely because of the nature of having to compete in the free market.

      Some people believe, if you can get the government to pay for something, it’s free. It isn’t. We’re going to pay one way or another, either through private insurance or taxes. The only difference if we pay it through taxes, aside from having fewer choices and less control over our own healthcare decisions, is that some people will pay more than their share so that other people can pay less. If you believe redistribution of wealth is one of the primary roles of government, that’s a good thing. If you don’t, it’s not.

      It’s true that health care costs are too high. One of the reasons for that is the exhorbitant cost of malpractice insurance. IMHO, tort reform would help. If a doctor is negligent or incompetent, he should be held accountable for his mistakes. On the other hand, just because a tragedy occurs doesn’t mean somebody has to get rich. Overregulation of the pharmaceutical industry also adds a lot to health care costs. I’m not against all regulation, but there needs to be a balance where we can have a reasonable assurance of safety without making making useful drugs unaffordable or unavailable.

      (https://notyourdaddy.wordpress.com)

  • Stephen Gregg

    Senator Kruse is on the right track. Suggest amplifying his thinking by focusing on “what five policy decisions” could the highest echelons make that would have cascading positive sustainable affects on the system. Such definitive decisions as personal HSAs and “defined contribution”, “Inclusion of Medicare”, “Whose money is buying health care”, credible cost containment strategy; terms associated with covering the uninsured; voluntary vs. mandatory ideology. We should look to government to be a judge and regulator of the system and not an architect.

  • Sybella

    From a personal perspective, not only should the government stay out of my health care decisions, we as the ones carrying medical insurance also need to be a little more circumspect. Ok free health care to the poor. That leaves it open for abuse. True when any of us are sick, we should be able to get health care, but to take your child to the emergency room because it sneezes!!!???. We as citizens help increase costs. We all want perfect health, including myself, but each time we run to the doctor or hospital to make sure we aren’t just suffering from the pangs of old age and want to reverse it. That does increase costs. Not only that we want it all paid for so we don’t have to. My other complaint is the mandates. I’m 64 years old (just a kid) and my premiums increased $60.00 a month this year. Gee just think now I can get my contraceptives paid for. Talk about the epitome of stupidity to require all these things as a matter of course. Between the government and us people, we are creating a juggernaut. You bet something needs to be done as well as requiring responsibility on both sides.

    • Steve Buckstein

      Sybella, you make a very good point about how mandates increase health insurance costs. The Oregon legislature actually added three mandates in its latest session, bringing the total to 33. Legislators of course do this with the best of intentions, and then wonder why fewer people can afford the insurance at all. For a discussion of this situation see Cascade’s quick commentary following the session: “New Mandates, New Costs” at https://www.cascadepolicy.org/2007/07/17/new-mandates-new-costs/

    • dean

      Obvious problems with our existing health care system:
      1) It is the most expensive on the planet at 15% of GDP
      2) At any moment, about 50 million Americans lack insurance (and that number is growing year by year)
      3) The U.S. ranks 37th in total health care effectiveness worldwide.
      4) Private insurance companies control costs by keeping high risk people out. (try finding individual insurance if you have had a serious illness). This forces high risk people into the public system.
      5) The lack of insurance portability ties people to jobs they might otherwise leave to start their own business, thus stifling creativity.

      The basic Democratic proposal by all 3 major candidates
      1) Prevent private insurance companies from charging different rates for different risk people. They would have to accept all who can pay the basic premium equally. (This is called “community rating, and is already used in Vermont, New York, Massachusetts and New Jersey)
      2) Subsidize insurance for low income working families (expanding Medicaid)
      3) Mandate insurance for everyone. No one gets to opt out, like we already have with car insurance in most states. Mandates could be on individuals or employers or both.

      These 3 steps would give us universal health insurance, delivered mostly through private insurance companies and private sector doctors. They would not however, reduce our high costs.

      4) Allow people the option to buy into Medicare or an equivlant at a price that reflects the actual costs to the government. In other words, government insurance gets to compete head to head with private carriers. If they are better, more efficient, etc, they get the customers. If not they gradually lose market share.

      This last step would likely lower costs. The mixed system described above is basically what the Germans have had for years and their costs are much lower than ours, while their quality of service is comparable or better.

      No leading Democrat is proposing a Canadian (single payer) or British (socialized medicine) system, so why offer those up as comparisons?

      • Sybella

        You never get the point. The object is to keep the Government out of our health care. I don’t want them involved. They are always stirring the pot. That said, go let them stir your pot, but I do not want them in mine. I have that right. I don’t want to pay a higher premium because somebody is sicker than me. I don’t want the government mandating anything. And I do not agree with you. You can let them run your life. I do not want them to run my life. What part of that don’t you understand.

        I do not care about the Germans, British, Cubans, any Europeans. If you think that is so great you go live in their mixed system, whatever that is and at this point in my life I think I’m old enough to make that decision as well as smart enough.

        • dean

          Syb…would you have the VA health care system abolished? Also Medicare (for the elderly) and Medicaid (for the poor)?

          Government is already deeply involved. Do you really think we are better off with no Medicare?

          Unfortunately for both of us perhaps, we are citizens of the same democratic nation, so have to share the same pot medical policy wise.

          • Sybella

            I do not want them any deeper involved than they already are. We may have to share the same pot if it is forced on us, but not willingly. I do not think the Europeans have any better system than us, nor as good. We have an excellent system, it just isn’t allowed to operate with out interference from those who think they are smarter and wiser than the rest of us and want to control all aspects. As Steve said, it may be with the best of intentions, but does not work. Why are you so insistent on making it worse?

      • Margaret Goodwin

        There are several problems with mandating that everybody must have health insurance. Not everybody will be able to afford it, even at cut-rate government prices. Sure, it _might_ cost less than what’s available today, especially for those who are subsidized, but people living from paycheck to paycheck who choose not to purchase health insurance today may not feel they can afford even the “cheap” health insurance that will be available tomorrow. They’ll have to give up something else to pay for it. There’s nothing wrong with making tradeoffs — as long as they’re voluntary. But this is involuntary. What will the penalty be for those who opt out? Jail time?

        Also, once it’s mandatory, there will no doubt be “health insurance” companies popping up offering very cheap health insurance that doesn’t really cover anything, but costs a lot less than a real plan. People who don’t think they need health insurance will buy those plans because they’re the cheapest way to satisfy the legal requirement, but they won’t get any benefit from them. They’ll just be funneling money to charlatans to get the government off their backs. How does that help solve the healthcare problem?

        You mention that car insurance is mandatory today, but it’s only mandatory if you have a car. If you can’t afford car insurance, you can opt out of owning a car and use public transportation. That’s a choice. With mandatory health insurance, there’s no way to opt out. IMHO, the government shouldn’t have that much control over how people choose to spend the money they earn. Just because you believe everybody ought to have health insurance, you don’t have the right to require them to buy it. If you want to give it to them, that’s a different matter. But then, whose pocket do you take the money out of? (Not mine, please. I believe in personal choice, and the personal responsibility that goes with it.)

        For other reasons why the Democrat healthcare proposals are a bad idea, see “Could HillaryCare Lead to Lifestyle Legislation” on https://notyourdaddy.wordpress.com.

        • Sybella

          Thank you, very well put.

          • dean

            Syb…first, if I thought the democratic proposals were going to make our system “worse” I would not be for them. I’m a pragmatist, not an ideologue.

            Second, you may not think Europeans, Canadians or Austrailians have health systems as good as or better than ours, and there may be aspects of our system that are better than theirs (i.e. shorter hip replacement waiting periods). But statistically we pay the most by far, insure the lowest number by far, and rank number 37 in overall results (life expectancy, infant mortality, etc) according to the World Health Organization’s objective rankings. The highest cause of individual bankruptcy in the US is due to health expenses by the way, suggesting that “health savings accounts” would be next to useless in a real emergency.

            Margaret…yes I agree. There are the problems with mandating that everyone have insurance that you cite. I don’t know what the proposed penalty would be. Probably paycheck garnishment for scofflaws.

            Rationally, the only people who choose no health insurance if they can afford it are those who are young and healthy. I did that myself back in the day. The odds were in my favor, and I made it to age 35 in good shape.

            We could do all the other steps I mentioned and allow people to opt out if we value individual choice over what is good for the many. One result is that insurance costs will stay high for the rest of us because the insurance companies base their rates on the statistical health of the pool, and if the young and healthy are not in the pool then everyone else pays more. A second result is: what do we actually do as a society when young strapping Johnny ends up needing chemo even though he thought he didn’t need insurance? Do we let him die? He chose the risk after all. Or do we force the hospitals to treat him anyway, and then they pass that cost on to us.

            The cheap insurance that covers nothing is already out there, and as an independent buisinessman I get solicitations nearly every day. Unscrupulous business practices are the reason why we end up with regulations and mandates Steve Buckstein mentioned.

          • Steve Buckstein

            Dean, you say “Unscrupulous business practices are the reason why we end up with regulations and mandates Steve Buckstein mentioned.”

            I don’t think they’re the reason, I think they’re an excuse. Reasons include misguided attempts to protect people from their own bad decisions, and perhaps some insurance companies using legislation to disadvantage their competitors.

      • David from Eugene

        Dean

        There is a sixth problem with the current system, the ever rising cost of employer provided health care is making American Companies non-competitive in the world market.

        As to the Democratic proposal you outlined, it would leave me paying money for insurance that does not provide me any coverage. The problem is no coverage for pre-existing conditions. I am over 50, most of my health problems have been identified, as identified problems are by definition pre-existing, the insurance will not cover the care I need.

  • rural resident

    Health care is a difficult thing for the government to do at the state level. If the benefits are too generous, people currently without decent coverage will move here from other states, putting pressure on the system. Oregon doesn’t have the resources to handle such an influx.

    Sybella, you’re right about the effects of mandating coverage. None of the plans I’ve seen seem to address the situation you mention, where people end up buying minimal coverage that doesn’t address their needs. However, given the deficiencies of the current (mostly) free market system, I think you’re moving toward the wrong fix.

    Medicare operates fairly efficiently, which suggests that Democratic candidates may be unwise in taking single-payer plans off the table (if indeed they really are). This may well be one area where, because of the potential financial impact on individuals and the consequences of not having adequate care, government involvement isn’t necessarily bad.

    One approach might be to expand Medicare first to those under 25 or 30, because they are the easiest and cheapest to cover. Just as with Medicare, there would still be some need for “medigap” plans that would keep the insurance industry involved — though I wouldn’t shed any tears if they were taken out of the game altogether by making it mandatory for providers to accept the “Medicare” payment as payment in full for all services. This approach would mean that children and those just starting out in the world of work won’t have to worry about medical costs. Once we know the cost of this, coverage could be expanded on some schedule to those 30-39, then 40-49, then 50-65.

    The Medicare portion of the social security tax can be increased. Employers currently being responsible and providing health insurance would likely recognize a benefit. Those not providing such benefits would have to start paying a share. Nobody likes tax increases, but as long as there is a substantial benefit to society, it makes some sense.

  • Jerry

    The government has no business being involved in any way with paying for health care.
    It is as simple as that.

  • carol

    Darn, there go my New Year resolutions already. I was determined to just read, not contribute, but it seems to be impossible to MMOB.

    I worked for a company that administered health care insurance for 20+ years, I saw claims that were unbelievable, and later when I moved to the billing department, I saw the result of the claimants demanding to have all costs paid. When I was raising my family we paid for a routine visit to a doc, and it was affordable. Now the insured expects all visits to be covered, with no more than a small co-pay.Because the cost of those who can’t pay is factored in, an office visit is no longer affordable.

    Pharmaceuticals are responsible for a 20-25% of the PREMIUM cost, and generic drugs are not the reason, the drugs that we need to “ask your doctor if this is right for you” are what drives up the cost. Do you think that marketing is inexpensive? We aren’t paying those exhorbitant costs for research and development. As for BC, the expense there is cheaper by far than childbirth, unless we get into the realm of infertility, that is an eye-opener, and is covered in many plans, as are visits to a chiropractor, sometimes 2-3 a week for a year or more at $100.00+ a visit.

    I guess the point I am trying to make is that we have created a monster. Those of us who are covered by the employer demand to be covered for everything, which makes coverage unattainable for many, sending them to the ER. Insurance companies are not in the business for their health, (pun not intended), they are there to make a profit, and that’s what they will do. If costs exceed income, the premium will be raised to create that profit, and thus premium costs raise each year, many years the percentage of increase is into double digits.

    The fortunate ones having health coverage paid by the employer, are finding that they are expected to pay more for the coverage, as the employer can’t be expected to cover the entire cost as it continues to rise. I have no idea what the answer is, but I have lived long enough to realise that nothing is free, and until we all realise that we need to examine what seems to be free, we will continue to pay.

    • Sybella

      You made my point exactly. We expect full coverage, You have probably seen the results of the end of the coverage year when everybody rushes to the hospital, doctor to have all the tests done before they have to pay any of it. People add considerably to the cost of insurance because we are terrified, ergo the media, that we are going to not feel perfect. We want and we demand.

      If you are correct on the 20-25% of insurance cost being pharmaceuticals, I am paying approximately $100.00 a month for a policy that requires I pay the first $1000.00 a year, leaving $200.00 of my prescriptions paid. In my case my prescriptions cost me throught Costco about $75.00 every three months. At $75.00 times 4 my total cost is $300.00. That doesn’t come any where close to my deductible. Now by giving the pharmacy my insurance information, I am limited to a 30 day supply and my annual cost was about $1200.00 give or take. So my $300.00 worth of prescriptions ended up costing me about $1500.00 annually not using my coverage.. Something is sadly wrong here. Less than ten years ago, I had the option to have prescription coverage and as I was still a healthy 54 years old I did not take it because my needs weren’t that great. A couple years later it was mandated and my premiums rose. I still don’t need it why is it foisted on me?

      Medicare now gives me the option of prescription coverage, but at least now it is optional. I will be eligible in four months. Now we all agree Medicare is a government plan, now if the government coverage is so great, why in the world then do we need Medigap coverage. This proves to me that national healthcare is not the solution. The rural resident suggests expanding Medicare to those who are not retired. My question to him is when he gets to pay for it will he still be as happy. Currently he pays 7.65% of his wages for Social Security and Medicare. His employer pays another 7.65% total 15.3%. Is he willing to pay more or is he one of the ones coming into my office complaining his head off about how much taxes are taken from his pay. Now if anybody is willing to give 50% of what they earn to the government, I say let them. I am not willing.

      I’m glad you broke your resolution, I hope others read that and pay attention.

      • carol

        A-h-h, Sybella, be sure that you read the small prinit on the Medicare Rx thing, I am on Medicare, and it isn’t exactly optional. If you don’t take it originaly, the the cost per month increases by a percentage each month, and it will be more expensive when you do take it, in other words, the INSURANCE COMPANIES that administer the plan don’t want only the users on the plan. When I started, I chose the least expensive plan that was offered for this area, since I don’t use drugs, and I figured that I would be OK for the year, since we are offered the chance to change plans each Dec. I had no claims, and I paid $6.00 per month the first year, $15.00 the second year, and this year would have been $23.00. All with no claims. I switched to AARP coverage, which was only a couple of bucks higher, simply because the situation p—ed me off. The plan that I originally took was sponsered by Walmart, and I have sworn never to buy anything at Walmart, I went against my better judgement simply because the plan was so much cheaper. I shoulda known better.

        I retired much later than I planned, simply because I hated to give up my insurance benefits, thinking that I couldn’t afford to pay my own costs. At the time I retired 2 years ago, the company was paying $1200.00 a month for med, dent, and vis for me. Not cheap.
        and the plan had been down-scaled twice in order to make it that affordable. At the time I retired, I had access to the Rx claims, and the difference between generic and brand name drugs is unbelievable. When the regulations allowing pharmaceutical companies to advertise, the cost of drugs began to sky-rocket. I have grand kids working for docs, and they say people come in asking for a specific drug that doesn’t even relate to their condition. Duh!!

        I think that a universal health plan that doesn’t require an insurance company to administer it would be ideal, a plan that allowed X amount of $$ for health costs each year, the insured gets to stash the extra from year to year, with some type of catastrophic coverage, in the event of severe illness. That ain’t gonna happen, the insurance and pharmas have too much clout in Washington, and it doesn’t matter who is in control fo the government. When it costs millions to get elected to public office, the $$$$ have to come from somewhere. The $$$$ don’t come without strings attached. As I said, I don’t have a solution, sorry ’bout that

        • sYBELLA

          I understand the prescription coverage. I also understand my situation and my ability to pay if my prescription cost rises. I still am not signing up for the Medicare Prescription. It isn’t cost effective.

      • dean

        Carol…I think it was a lousy and unsustainable resolution, so welcome back, even when we disagree.

        I’m not discounting your experience in the industry, but statistically about 20% of us gobble up 80% of the total national cost of health care in a given year, while 80% don’t use many if any services. Staying healthy day to day, particularly when one is relatively young is no great shakes. But when the wheels come off it takes a lot of effort from a lot of people and that is what costs so much. Not the tschakas.

        The World Health Institute ranks France number 1 in the world for health care results. Basically what they have is what rural resident suggested, a nation wide medicare-like insurance program that covers every citizen paid for out of taxes. Taxes are obviously much higher than here, as Syb sugests they would have to be. To keep costs low, France also encourages people to buy additional supplimental insurance like we do with Medicare. This additional insurance is subsidized for the poor. France by the way, spends far far less than America per capita on health care.

        The problem that leading Democrats other than Kucinich have come to realize is that America can’t establish a single payer insurance system paid for out of taxes because resistance from the private insurance companies, doctors, hospitals, drug companies, and small government conservatives would stop it in its tracks through a fillibuster, even if the dems win the Presidency in 08 and retain Congress.

        So we are stuck with a hybrid system of partial government & partial private, which has huge overhead costs, is terribly inefficient, and leaves many of us with a lot of insecurity over where we will get our health care from if things go south. In my case, as a small business person, as long as I am healthy I can work and pay my monthly premium, which presently runs about 10% of my pre-tax income. If I got too sick or injured and could not work then I could not pay my premium and would lose my insurance. Bankruptcy would follow shortly. That happens to tens if not hundreds of thousands of Americans every year. Is this really the system we want, just so we can say we are keeping government small?

        Syb…without Medicare, as you age further you would be out in the cold. Private insurance companies would drop you like a hot rock or raise your rates to the point where you could not possibly pay. So give some thanks to what little socialism we liberals have managed to foist on you conservatives.

  • carol

    Dean–
    I think perhaps that you rwere responding to my first ramble, not my second. What the heck do they call these discussions, I don’t seem to know the idiom.

    What I am saying, is that we need to be more responsible for our own charges. If each of us had a set amount to spend, and of course it would have to come from somewhere. Say we had XXX amount of $$$ from the government, and when we have spent that, we would be OOP, then we would think twice before going to the doc for a cold, AND demanding meds when we get there. As it is now, the pharmaceutical and insurance companies determine how the $$ are spent. If we were OOP for the entire cost of meds, then there would be a h—uva lot more generic drugs purchased. As I stated, in my job, I could see, on the screen, what brand name meds cost. Most health plans now, have a three-tier system, and inevitably, the drugs that we are bombarded with nitely on the tube, are on the top tier, go figure.

    I agree with you that Kucinich’s plan makes sense, more than any other that I have seen, but in whose lifetime will such a plan transpire. I’ll willingly bet my farm, that it ain’t gonna be in mine. These guys don’t get elected for free, dems or GOP, and when they take office the bill comes due. Where do you s’pose that Dubya got the $300 mil for his first primary, from the petroleum companies maybe, n-a-a-h, nasty me for even suggesting such a thing.

    • dean

      Carol…yes, it was the first ramble.

      I don’t disagree with you that it is probably better if we have the incentive to opt for generics and forgoe other unecessary expenses.

      The 3 main dem contenders all have verions of what i outlined in an earlier post. Not as good as what Kucinich is for, but much more realistic politically. And if it is done in a way that allows direct competition between an expanded Medicare and private insurance, then over time the privates will either get way more efficient or they will fade into the sunset, as will we all in due time.

      So vote dem in November. You and I are about the only ones in this discussion (I dunno what to call it either) who will.

      • carol

        Dean, I intend to vote dem in the national election, not so sure about th e next state, look what that got me. You are missing my point, tho, with the politicians spending BIG bucks, some entity is gonna collect once they are in office.

        As far as health care is concerned, sd long as somebody else, ie the insurance industry, is paying, we, the insured, don’t give a rip. that’s human nature, and if the $$$ come out of our pocket, (OOP), then we sit up and take notice!

        If each of us had a set amount of coverage to cover nominal costs, and high deductible insurance covering for extreme costs, we would pay attention to what we were being charged. I know that this is where I will lose you, but I have seen enough in the years that I have lived to know that we have become, on the whole, a gimme nation. Maybe a depression would be good for us, last time the rich lost their shirts also, and I believe the rich would have to barricade themselves well, in order to keep what they have, given the sense of entitlement that the rest of us have.

        So, I don’t know where my politics lie, left, right, or center. Conservative, or liberal, I only know that human nature governs us to take what comes easy, and we have to think far enough ahead to make make the needed choices. I have been, in the past, both anti-union, and pro-union, and I can see both sides of the coin, I think that given where we are now, in this country, I feel the unions are a neccesary evil.

        • Margaret Goodwin

          Carol, you are correct that, as long as people get something for free, they’ll treat it as though it were, well, free. When they have to pay for it themselves, they think twice about whether they really need it. As I pointed out before, people think if the government pays for something, it’s free, and they might as well take advantage. People who are gainfully employed are less likely to take advantage because they nave more demands on their time and just can’t afford to take the time to run to the doctor for every scratch and sniffle. People who have more time on their hands are more likely to take advantage. And those are generally the people the government will be subsidizing — the ones who are most likely to take frivolous advantage of the system.

          Also, many expensive health conditions are the result of lifestyle choices that lead to obesity, high cholesterol, various forms of cancer, liver damage, hepatitis II, STDs, etc. As long as someone is paying their own way, it’s their own business if they make bad choices. However, when they’re subsidized by the taxpayers, their negligent/self-destructive behavior costs everybody except themselves. Why should those of us who earn our way, and take care to make responsible choices, be charged extra so others don’t have to take responsibility for the consequences of their own reckless lifestyle choices?

          Regarding pharmaceuticals, many prescription coverage plans require higher co-pays for non-generic drugs, or don’t even cover non-generics unlesss there is no generic equivalent available and the drug is deemed medically necessary. It seems that should mitigate the problem of people demanding “ask your doctor” drugs. What am I missing?

          • carol

            I worked for years ‘admistering’ a health plan for those who were gainfully employed, and they found pleanty of time to seek medical care. So it is not the ones who are not paying their own way, as you say. No one can afford to pay their own way with today’s medical costs, the insurance company pays, and raises everyone’s premiums in order to make a profit.

            As for the different cost for RX, ie brand vs generic, the different co-pays don’t reflect the cost of the drugs. There is an enormous difference.

          • Margaret Goodwin

            Carol, I wasn’t suggesting that anybody today pays their own way without insurance. Yes, the insurance companies always pay, but they pay more for those who run to the doctor at the drop of a hat, and those who use it less cover the costs of those who use it more.

            My point about those who aren’t earning their own way wasn’t intended to imply that working people never abuse the system, but that, once it’s free, it’s more likely to be abused by those who have fewer demands on their time. (I’m lucky enough to have great medical coverage through my employer, but I hardly ever use it because I’m too busy to take time out for anything that isn’t essential.) Basically, I’m in agreement with you that, when something is free (or somebody else is paying), people tend to use it more indiscriminately than if they have to pay for it, and that raises the costs for everybody.

            WRT different co-pays for generic/non-generic drugs not reflecting the actual difference in cost, why don’t the plans just not cover non-generics unless a generic substitute isn’t available? Then people who really believe it’s worth the difference in cost can pay the difference in cost, and the rest of us don’t have to.

          • carol

            I can easily see that in the future, but it’s a scenario with the insurance co.s vs th pharmas. Should be interesting. It would be nice if we could cut out a lot of the overhead from both parties. Nice if advertising for an essential product were regulated, if not barred entirely. But of course I’m an old fogey. When I’m talking the price of brands, some of them are upwards of $300.00 or more, as opposed to generics at less than $20.00 generally. Co-pays usually run the gamute from $10.00 to $50.00.

  • rural resident

    Sybella …. Tax revenues need to be spent wisely, and this seems like a wise use. I’m not one who complains bitterly every time the government so much as raises the price of making a photocopy on the machines at the capitol office buildings.

    Taxes are what we pay for government goods and services. I realize that conservatives generally don’t want to see the state or the feds play a role in medical care, but it has become obvious to a large segment of society that the current “free market” approach to providing health care for people under 65 (other than the very poor) isn’t getting the job done. I’ve had several personal experiences within my family where people paid PLENTY out of their own pockets for health care and watched as doctors and insurance companies refused to provide services that were both necessary and warranted. This was someone who almost never made use of the medical system. (Seeing a physician once between the age of 52 and the age of 84 I think, one would agree, constitute an “infrequent user.”)

    The current system isn’t as perfect as the detractors of national health care suggest. The insurance companies have a stake in denying care. It makes their profits larger. HMOs receiving capitation payments don’t want to do any more than the minimum necessary to keep people alive so they can continue to receive payments. Doctors are scheduled so tightly they can hardly breathe, let alone spend the necessary time with patients who have appointments. That’s not acceptable in today’s society. And, increasingly, that’s where the current system is headed. That’s why the federal government should — and soon will — play a much larger role.

    I agree that people can’t be running to doctors everytime they have a runny nose or a hangnail. We need to find some incentive for people to get preventive care without going overboard. And we can. Carol’s idea about a limit on government payments in a given year is OK, as long as we’re not applying it to someone with a major illness. That’s where things get expensive and where the system starts to break down. Institutional cost controls can help reduce costs on an overall basis; including a measure of personal responsibility for using the system appropriately is also needed.

    Enough people agree on the fact that we can’t continue to leave 40-50 million people uninsured with the rest of us picking up the tab for their emergency care.

    • carol

      I didn’t direct my response to this post, check # 10 for the one I intended for here

  • carol

    Sybella,
    That’s why I say that one has to be very careful what type of coverage one chooses. Any coverage that needs a referal to see another doc, isn’t wise. A plan where you are required to stay within the group, such as Providence, Legacy, etc, or pay a penalty gives you much more choice. I would say that none of the plans will cover what they consider to be experimental medical charges.

    When you go to Medicare, if you take one of the Medicare advantage plans, you will not have to pay for additional supplemental, or RX coverage, but you may be limiting yourself severely. I have opted to pay for sup coverage with AARP, and pay for the RX plan. I have had limited claims, (I had both knees replaced under my old coverage), but my husband has had a lot of medical care, and we have not been refused, or paid for any thing out of pocket in the two years since I retired. We pay several hundred a month more for coverage, but “peace of mind” is priceless.

    • dean

      The way other countries control health costs is by setting national budgets, which is why Canada is pointed to by our free marketers as a bad deal since one has to wait a long time for hip surgeries and such.And my understanding is that Canada does not allow people to buy private insurance to suppliment what the state offers. They could solve a lot of problems if they did so.

      We not only have 40-50 million uninsured, we also have about that number under insured (i.e. poised for bankruptcy) and just about any one of us not rich and under 65 is at high risk of being tossed from our present insurance (if we have any) at any moment.

      Our system is fatally flawed, others do better for less, and it is time we all woke up. The free market is not going to solve this one.

    • Sybella

      Thank you for your advice. I have already researched my medical coverage when I sign up for Medicare. I will not be taking Social Security though at this time.

      There are many excellent medigap policies out there, I think I know which one I’m going to. The Medicare Advantage plans do not intrigue me because of their limitations. I do not like the idea of an HMO either. The cost of my drugs also is not a concern to me. I am concerned though about my health care. I am concerned about major medical, not the daily in, out. I work very hard to stay as healty as I can, diet, exercise, etc. Yes, things can go wrong and I believe we are all responsible to cover ourselves. I just think instead of always looking to government to supply our needs, we should just use our heads for something besides keeping our ears apart.

  • carol

    RR,
    In a later post, I said that supplemental coverage, with a high deductible is necessary for catastrophic coverage. If a set amount, call it a medical savings account if you will, was available for everyone, and the aforementioned supplement, each individual would have to wake up and pay attention to where the $$ were spent. Granted, there are some who wouldn’t grasp this at first, but in time it would become obvious to almost all. There would be kinks to be ironed out, no doubt, such as a limit to what could be ‘banked’ for the young and healthy.

    However, the system, as it stands, is costly and unwieldy, and universal, government paid health care is an invitation to disaster. Any time that we take responsibility out of the hands of the individual, and give it to an organisation to manage, it’s gonna cost.

    The generations after the ‘greatest generation’, of which I’m right on the cusp, have come to take a lot of things for granted, and don’t always realise the actual cost of entitlement, and that’s what it is, Dean, there is no other word for it. The more that comes easy, the more that is expected by those that receive it. I’m fairly liberal, but a long way from stupid. And old enough to have seen a lot of changes in this world. I don’t want to go back to things as they were, I washed clothes on a wringer washer, for God’s sake, but a small return to ‘the good ol’ days’ would be a refreshing change.

    • dean

      Carol…okay, our values are similar and I did not raise my own kid to expect easy handouts. National health insurance is not a handout. under any conceivable structure we would all pay something, some more and some less depending on income, whether that is paid to the feds through taxes or to private health insurance companies through mandates (i.e. verily, thou must have insurance). Its pay to play unless you are really poor or disabled.

      So it is clearly not something for nothing. It is something for something. The point you bring up, if I understand you correctly, is that there should still be some out of pocket costs or incentives to the individual who would otherwise have no incentive to save the larger pool any money, by opting for lower priced drugs for example. (Under a single payer system by the way, this would not be necessary since the government would use a formulary to decide which drugs would be paid for. It would not be up to the patient to choose one over the other).

      But in the absence of a single payer system I agree with you that there needs to be some way to encourage individuals to make economic choices. I’m not sure how it should be structured. Your way sounds fine.

      There are many ways for people to game, or free ride on the system. Too many to count really. I see a lot of posts on this site that indicate people think they ought to be entitled to this or that government service without having to pay taxes (i.e. good roads with insufficient funds for maintenance, high prison populations, etc…). I see so called fiscal conservatives in the White House and Congress run up deficits year after year and create free trade agreements that ship good paying jobs overseas. And I see fellow liberals who don’t understand that without private businesses and market innovators we would be trying to discover fire or invent the wheel by committee.

      But nations that have much better social safety nets than ours manage to be quite productive, have lower crime, less people in prison, and so forth. The least of my worries is that patching up our own safety net is going to make us too soft in the middle. I think it would make us more competive internationally and make us secure enough to encourage more risk taking and innovation, not less.

      A universal health insurance system, single payer or otherwise, is far overdue in the country. The private insurance industry has had 50 years to come up with an affordable, fair, efficient, system It has failed and it is time to move on. Republicans like Senator Kruse have nothing to offer on this issue but more of the same.

      • Tim Lyman

        Dean –

        I was raised in Canada. I have two brothers still living in Canada.

        My father died at 64 from an operable form of cancer because of the waits involved for referral to specialists, tests and hospital beds. A process that takes a week or two in the US took a year in Canada. One of my brothers is has been waiting over a year for a hernia operation currently scheduled for June of 2008. His hernia is so severe that he has difficulty walking.

        If you are young and healthy and suffer a traumatic injury, the system works OK (you get 2d class care from third world doctors) as long as there are no complications requiring exceptional surgical skill. If you are seriously ill or in need of elective surgery (and much of what consittutes elective surgery in Canada is what is considered required here, ie: my brother’s hernia) you might as well make a will. It’s worth noting that a far-left Canadian Cabinet Minister recently chose to come to the US for “elective” surgery on a life threatening condition that wait for her turn in Canada. Further, the system is now so broke that much of the preventative care that was once covered now must be paid for out of pocket.

        I will tell you the same two things I tell everyone who thinks socialized medicine is so great:

        1. Move to a Canada for a year and tell me how you feel. Failing that, talk to average Canadians who have experienced, or whose aging parents have experienced, life threatening illnesses and had to seek treatment in Canada.

        2. It’s better to be bankrupt than dead.

        • carol

          I’m not sure that the same problem is not becoming apparent here. My sis in SF, is having problems finding a doc to deal with her back. It seems that many of the good ones are becoming subscription docs. For a mere 15 to 30 grand per annum, you can be guaranteed the very best of care, any time, any where. She’s not broke, but stubborn. I almost believe that she’d rather be dead.

        • dean

          Tim…first, I have not advocated that we replace our system with Canada’s, and I don’t question your family’s unfortunate experiences. What the leading national Democrats are proposing retains our mostly private insurance system, with the changes I outlined in an earlier post.

          But…let’s go ahead and compare the Canadian and US systems across a range of issues, using commonly available statistics.

          On cost, Canada spends just over 1/2 of what we spend per capita yet they insure 100% of their citizens while we insure about 85% of ours, 29% directly via the government (Medicare, Medicaid, and VA).

          Interestingly, the US GOVERNMENT (taxpayers) ALREADY spends more than the Canadian government per capita on health care, even though we insure only 29% of our citizens via government while they insure 100% of theirs. That one is worth dwelling on by the way. WE ALREADY SPEND MORE THAN THEY DO IN TAXES FOR HEALTH CARE!

          The world health organization (WHO) ranks Canada 30th in overall quality, the United States 37th (among 191 total nations).

          (Most Americans who lack health insurance are working full time by the way. But at jobs that do not provide insurance).

          Doctors and hospitals in both countries are private sector (except for our fine, overworked VA doctors). In Canada doctors bill the provincial governments for their services, while in the US they bill either the patients, their insurance carriers, the government or all 3 (making for a lot of paperwork all around)

          According to peer reviewed surveys, U.S. residents are 1/3 less likely to have a regular medical doctor, 1/4 more likely to have unmet health care needs, and are more than twice as likely to not get needed medicines.

          Waits in Canada to see specialists, receive elective surgeries like hip replacements, or to get radiation for breast cancer are around twice as long as in the US on average (assuming the US individual actually has decent insurance).

          For US citizens on Medicaid waits can be as long or longer than in Canada because low payments reduce the doctors available.

          Canada has longer life expectancy by 2.5 years and lower infant mortality than the US. By most measures Canadians are healthier than Americans.

          Administrative costs are much higher in the US than in Canada.

          Medical professionals in the US are higher paid than in Canada.

          Drug costs are far lower in Canada. We spend $728 per capita each year on average while they spend $509, yet their patients get MORE prescriptions than ours. Republicans have been very good to drug companies by preventing Medicare and Medicaid from negotiating prices.

          The American per capita death rate from cancer is HIGHER than in Canada.

          So Tim…you say “better bankrupt than dead,” yet statistically you are more likely to die sooner in the US. In Canada you can stay alive and avoid bankruptcy (while waiting for hip surgery perhaps) while here you get to die younger and broke.

          Also, Canada does not have “socialized medicine.” They have ‘socialized insurance.” Britain and Cuba have socialized medicine, meaning medical professionals all work for the government, like our VA doctors.

          If it were up to me, I would take Canada’s system over ours unless I were upper middle class or rich. But we have choices available that are probably better than either system and certainly more acheivable politically, given the opposition of our for profit insurance companies, drug companies, high paid surgeons, and small government zealots.

          • Margaret Goodwin

            Dean, when you refer to what the US government spends per capita on healthcare, it’s unclear whether per capita refers to all Americans or to all Americans covered by government healthcare programs. Can you provide a link to your source for clarification?

            Also, the fact that Canadians live, on average, 2.5 years longer than Americans, and the fact that Canadians have a single payer health plan, does not imply that Canadians live 2.5 years longer than Americans _because_ they have a single payer health plan. There may be many other factors having to do with lifestyle, different demographics, smaller urban concentrations, etc.

          • dean

            Margaret, the source is the World Health Care Organization Core Indicators. Hit that on a search and you will go to their site. I used a secondary source that cited them.

            My understanding of the statistic, and it shocked me when I read it, is that In 2004, the government of Canada spent $2,120 (in US dollars) per person on health care, while the United States government spent $2,724 per person. When you factor in what we spend privately our total cost is almost double theirs per capita.

            I’m not saying they live longer BECAUSE they have a single payer system. I am saying, across the board, except for the near doubling of wait times for some procedures, they kick our butt and spend a lot less.

            Yes there are a lot of factors to consider, with poverty rates being a very important one. But we are probably closer to Canada demographically than we are to any other country.

            But hey…WE’RE NUMBER 37! Let’s all give a shout out.

          • Margaret Goodwin

            Dean, I looked up the source (https://www.who.int/whosis/database/core/core_select_process.cfm?countries=all&indicators=nha#) and it says the “Per capita government expenditure on health” in the U.S is 2724.7. In Canada, it’s 2215.4, which is 81.3% of the U.S. expenditure.

            It’s also signigicant to note that, in Canada, the “General government expenditure on health as percentage of total expenditure on health” is 69.8%, while in the U.S, it’s 44.7%. That means over 30% of health care costs in Canada are not actually covered by their “single payer plan.” The fact that 44.7% of total health expenditures in the U.S. are paid by the government is rather apalling, considering that most Americans are covered by private insurance. (Talk about inefficiency!) I was unable to find the statistic you quoted on the U.S. government directly covering only 29% of the population but, assuming that is accurate, the fact that almost half of all health care expenditures in this country are made by the government, to cover only 29% of the population, provides dramatic evidence of how much less efficient the government is in providing health care than the private sector. And yet, some people would like to turn over all health care to the government. Going by the the data we have today, we can only assume that healthcare costs would more than triple if the government covered 100% of the population instead of 29%.

            Here’s another _very_ interesting statistic from the same site. In the U.S., Out-of-pocket expenditure as percentage of private expenditure on health” is only 23.8%. In Canada, it’s 49.4%! And that’s in a country where, supposedly, the government covers everybody’s health care. (Apparently, they don’t cover it very well.)

          • Steve Buckstein

            Margaret, the WHO statistics site is clearly a very valuable source of information. The conclusion you draw about health care costs tripling if government covered 100% of Americans instead of just 29% may, however, be somewhat inflated. Medicare patients are a big component of that 29%, and according to the Center To Advance Palliative Care, end of life care consumes 10-12% of the total US health care budget and 27% of the Medicare budget (source: https://64.85.16.230/educate/content/elements/expendituresforeolcare.html).

            If the government covered everyone, costs wouldn’t be as high as those end of life costs, but would still likely be considerably higher than they are today, as I’ve sited in other Catalyst threads.

  • carol

    I don’t want the gmnt deciding which meds I need, that is open to all kindsa stuff. I want to decide where to spend, or not spend, my $$. For a long time when we were raising our sprouts, we didn’t have coverage, and we got by. Coverage, when we got it, seemed like it came from heaven. My daughter broke her arm, the ins only paid enough for a GP, not a specialist, and that’s what she needed for the type of break she had. We were happy to dig up the money for the specialist, and would have never thot of a lawsuit if thing had gone wrong.

    The extra cost involved was still within reach of a working person because the providers didn’t have to spend the bucks for mal-practice insurance. Later when our primary income was from farming, we went bare again, and healthcare was still affordable, but getting less so. Somewhere, between the mid to late 70s and the late 90s, something happened, and costs began to soar. I’m not sure what caused it, but I suspect that it came with insurance, and people thinking some one else was paying the bills. And the attorneys getting fat on lawsuits. Ask me if I will vote for Edwards.

    I am aware that I am not getting thru with what I am saying, and that things won’t change for the better, but I said it anyway. And that is a sure sign of age, that and the longing for ‘the good ol’ days’

    • dean

      Carol…back to statistics….
      Malpractice settlements, including attorney fees and so forth add an estimated $16 PER YEAR to the average insurance premium, and amount to less than 1/2 of 1% of our total health care costs. This is a total right wing red herring and you fell for it.

      Interestingly, Canadians also have malpractice suits, though way fewer than we do. And their settlements tend to be higher. Go figure.

      I’m not an Edwards fan for President either by the way, but if I need a good trial lawyer I want his phone number.

      You are getting thru just fine, but remember, nostalgia is not what it used to be.

  • Jerry

    You guys are all crazy. I say just pay for your own health care. Period.
    Leave me out of it, and government, too.
    OUT do you hear me??

    • dean

      No can do Jerry. Public health policy means everybody is affected. We are all in it together for better or worse.

    • Tom H

      There are too many people, Jerry, that insurance companies won’t insure at ANY cost because of prior conditions. Likely you will be one of them one day, too. What are they supposed to do?

    • David from Eugene

      Jerry, I hate to burst your bubble, but you are already IN and you are already paying for emergency room visits by the uninsured. The Doctors and Hospitals are already passing on to those that can pay the costs associated with providing care to those that can’t or won’t pay. And your insurance carrier is adding in its overhead and profit on those costs.

      The question is not whether or not health care for those who are unable to pay will be bourn the rest of us, but rather how we will pay, and how they will get care. The payment options are either ever increasing insurance premiums or some form of tax. The deliver methods are doctor’s visits or emergency room visits. It is a lot cheaper to pay for a doctors visit (about $100) then it is an emergency room visit ($700 plus). It is also cheaper to pay for a Band-Aid and a tetanus shot then it is to amputate a gangrenous limb.

      As long as hospitals must treat anyone that comes through the doors we will have this problem. And putting the moral and humanitarian arguments against allowing hospitals to refuse treatment aside for the moment and addressing the practical argument against that idea, do you want to die because a hospital refused you treatment because arriving alone and unconscious you could not provide proof of payment? I certainly do not.

      And one last point, regarding your own health insurance coverage, the Health Insurance System in the United States is in a death spiral. Higher health insurance rates causes an increase in uninsured which in turn increases amount of unpaid health care which in turn causes an increase in doctors and hospitals overhead raising the rate they charge the insurance company which causes an increase in health insurance rate. The system is going to collapse, the question is when.

      • dean

        I want to try and answer Margaret’s post #10 if it isn’t too late.

        Our federal government provides health insurance &or direct care to our poorest, our oldest, and our wounded veterans. Our private insurance companies refuse to cover anyone with pre-existing conditions, and for the most part cover healthy people in their 20s-50s who are working at good jobs, meaning they are middle class or above. Working lower middle class and poor people basically are uninsured, as are many middle class people with pre-existing conditions that make them uninsurable in most states.

        So of course on a per capita basis, private sector insurance companies spend less on health care than our government does. If they didn’t they would be out of business fast.

        I also want to correct something I posted way back. Barak Obama’s health care proposal DOES NOT include a mandate that everyone has to buy some form of insurance. Edwards and Clinton do include this mandate.

        All the Republicans still in the race seem to think our present system is just fine by the way. ‘Best in the world” harrumphed Fred Thompson last night. Number 37, at highest cost, with 50 million uninsured is best? Whatever.

        I fully agree with David above. The present system is collapsing of its own weight. Many of you who say “leave it alone” will be joining the rest of us demanding change soon enough, as more are left high and dry.

  • Jerry

    I think maybe it has collapsed already.
    This is stange stuff.
    If I might die without a car, would everyone chip in and get me one? If I might die without a house, would everyone chip in and get me one?
    Just thought I would ask.

    • dean

      Jerry…no on the car. But if you were broke and homeless I would chip in (or support taxes) to help get you off the street and under a roof. Three hots and a cot for everyone.

      What I think you are missing is that we are all already chipping in for health care for the 29% of our fellow citizens who are veterans, on Medicare or Medicaid, and we are chipping in through increased premiums to support “free” emergency care for those without any insurance.

      Proposals to create either a single payer or more comprehensive mixed system are more likely to end up costing us less than they are to cost us more.

  • Jerry

    I am not missing that we are “chipping” in, just wondering if we should be. No question on the Vets, though, not a problem at all.

  • carol

    Hey now Jerry, what about us old folks?

    • dean

      Jerry…so you are okay with helping to pay for socialized medicine for veterans. What would you do with respect to old folks and poor folks? The cold hard streets for them?

  • Jerry

    Families and friends can help them.
    They have not done anything to justify the support.

    • dean

      Families & friends can help them pay for a quadruple bypass surgery? Interesting. I wonder why people bother with any form of insurance at all?

      Jerry, with due respect what you are proposing is essentially a third world, village economy solution to health care. Its quaint, but not up to modern expectations and capabilities.

    • carol

      A-h-h Jerry, you must be terribly young, and so cynical already. Please refer to ‘The Greatest Generation’, an earlier post, I know you read it, I saw your name there. That’s where we old people came from, and a lot of the poor that you refer to are guys who got royally messed up in Vietnam. So messed up, in fact, that they no longer have friends, or family. Oh I forgot, they are vets, and worthy of your care. Get real! I remember some Wise Guy saying, “As you have done for the least of them, you have done for me” What if there really is a Heaven, and a Hell? Better listen up!

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