Why you can’t buy health insurance like auto insurance

September 8, 2009 | Aaron Keating

During the debate over health insurance reform, you’ll occasionally run into the idea that health insurance should be provided more like auto insurance. After all, in most states everyone has to have auto insurance, so everyone’s covered. If you have a decent driving record, you’ll have lots of choices among providers; and most people can find the minimum required insurance, even if it’s in a high-risk pool.

If the market works for auto insurance, why not health insurance? The answer is simple: People and cars are different. We (rightly) value them differently. And the market can’t account for that difference. Here’s why:

First, car insurance is a very restrictive form of catastrophic coverage. It doesn’t cover the everyday items that keep cars running, like oil changes; nor does it cover mechanical breakdowns, even when they cost you a fortune. You can put off an oil change, and eventually your car will break down, but your auto insurance won’t help you then. It only comes into play when you hit someone/something, or they/it hit you.

Your health is different. Your body can break down in numerous ways – cancer, pneumonia, or a collision with a bus, for example. To be effective, health insurance has to cover both preventative *and* catastrophic care, because the two are inextricably connected. People will put off a yearly check-up if it isn’t covered by insurance. (Yeah, you say you won’t, but the behavioral economists out there have the data – you will.) And when small health care problems go unnoticed or untreated, they become full-blown problems that cost a great deal more to treat in an emergency room.

Second, as the #2 comment on this post highlights, the replacement cost of your car is known. That means you and and your insurer can come to an agreement about things you would likely never agree on when it comes to your health, let alone life or death:

If the repairs on your car cost you too much, or take too long, you can always junk the car and buy another. That is, you may choose not to pay for repairs that exceed that car’s replacement cost–or are just too much of a hassle. Because you can always buy another car. None of that is true with health care. While my own body’s health problems are costing society $80,000 a year in maintenance, I can’t junk my body and get another. The Lord gives each of us only one body to a customer. And you have to pay to maintain it, no matter how much it costs–unless you prefer death.

In other words, there are no emergency rooms where you can get car-saving treatment regardless of your ability to pay.  There are only mechanics who will give you a quote for the work, and you can take it or leave it. And there is a good reason for that: as inanimate objects, cars have finite value.

But a moral society would never do that for people, because only a very few of us could afford the Life Flight helicopter ride from a crash scene. We provide emergency care regardless of ability to pay because it would be unethical to do otherwise.

Health insurance reform is about ensuring everyone has more than catastrophic coverage or the emergency room to rely on — because it’s healthier and cheaper for everyone, and ultimately better for our communities and our economy. If everyone can easily access and afford preventative care, that means fewer expensive trips to the emergency room.

A better analogy for health insurance is the local fire or police department. It doesn’t matter how much you earn, or how high up the social ladder you are, you get the same fire engine. Maybe you can afford better home monitoring and security if you are wealthy, but you don’t get better fire engines or faster patrol cars. And you don’t get a bill in the mail when a fire is put out, or a burglar is caught.

Odds are, you will need the fire or police department far less often over the course of your life than you’ll need a good doctor. We subsidize the cost of everyone’s personal safety with our collective tax dollars. Health care should be no different.

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Comments

  1. josh maher says:

    The fire/police department example is just as poor or worse then the auto insurance analogy. Since when did the fire department come to your home to check up on your electrical and gas connections? Since when did the police department come validate that your guns had locks on them and were in the gun safe?

    Forced coverage (i.e. everyone must buy in) is forcing everyone to buy a product whether they want/need the product. If I don’t want any vaccines, why should I pay for them? If I don’t need regular checkups because I am healthy, why should I pay for them? It is forcing a market because the current market won’t handle the load of covering everyone.

    If a market could be created where everyone is covered at their desired levels then the participation would be voluntary and everyone would be better off. Forcing a market to exist that wouldn’t otherwise exist is the same method Lennon used and we all know how well that worked out….

    • Well, the fire department doesn’t check on electrical and gas connections, but a building inspector sure does, and it’s a good thing they do. A gas leak or electrical fire is dangerous to everyone, not just the occupants of the building. Moreover, those purchasing a newly built home or office very likely don’t have the expertise to verify the building is built to code. Building codes and inspections raise the cost of building somewhat, but they ensure the market creates safe products through minimum standards we can all rely on.

      Every market needs public structures to function well (like courts to interpret contracts, roads to transport goods, etc.). Many markets also need direct intervention in order to prevent negative outcomes for society. Take, for example, the air, water and soil pollution that occur when heavy industries are left unregulated. The producer of the pollutant doesn’t pay for othe pollution in that case, but the people breathing dirty air, drinking unsafe water, and growing contaminated crops sure do. It might be “cheaper” for the industry to pollute, but it’s very costly for the rest of us.

      That’s true for health insurance as well. You might be healthy right now, but you won’t be forever. You can’t know when something will go wrong, and when it does, it will cost you a fortune in medical expenses. If you don’t have the money to pay for your care, then everyone’s insurance premiums will have to go up to cover your costs. Multiply that effect by millions of other uninsured people and you have one ingredient in today’s recipe for skyrocketing health insurance costs.

      The market for health insurance exists – I imagine most people without it would certainly like to have it – but the market is not serving their needs with affordable plans and adequate coverage. In other words, the market is broken. When that happens it is the government’s proper role to intervene and set new rules for that market to ensure it functions properly for everyone’s benefit.

      It is worth noting that under a single-payer health insurance program (used in many countries that, as a result, enjoy cheaper, better health care than we have here in the U.S.) there would be no individual mandate for health insurance coverage at all. Everyone would be automatically covered, end of story.

      • Walt says:

        Lets be real, the problem with rising health care cost are simply we don’t pay out of pocket directly for our services so we have little or no incentive to question the cost the providers are charging the insurance companies.

        At the company I work for, we use HSA health savings accounts and it works well. If you don’t see a doctor multiple times other then routine exams or have a lot of prescriptions, you roll that money into the next year to build a nest egg for later years when you get older and need more medical coverage. The majority of young people simply don’t have the serious health issues that require high cost of care so they should pay less for what they need and use. On the flip side the young pay more for auto insurance until they reach the age of 25 for most companies when the rates start to drop given a clean driving record.

        It simply doesn’t make sense when the President says we need more competition for the health care companies therefore we’re going to have them compete against the Government. Kind of like Ford competing against Chrysler and GM. Ford is competing currently but the Government has a much bigger pool of money it can keep dropping in forever by simply raising taxes.

        Letting private health insurance companies compete state by state and writing non mandated coverage would do a lot to bring cost down for everyone.

        And lastly, of course we have high health care coverage, have you noticed how obese Americans have become? This is largely a self induced problem with people who take no responsibility in keeping fit. Do you really think a Government plan with no additional cost for lifestyle choice would give them any incentive to change unless they did it by force?

        • Problems with our health insurance system stem from more than one source — and insufficient out-of-pocket costs aren’t one of them. In fact, out-of-pocket expenses are actually already on the increase for many workers:

          In 2007, adults with employer coverage faced an average of $729 annually in OOP costs for medical services, including deductibles and other forms of cost sharing such as copayments and coinsurance. That represents a 34 percent increase from 2004, when the average OOP burden was $545. Health plans covered a slightly smaller percentage of overall expenses in 2007 than 2004, but growth in overall health spending was the chief culprit behind rising out-of-pocket costs.

          It is the insurance company that dictates how much, or what percentage of, the cost of a procedure they will pay for, not the health care provider. Providers often raise their rates or prescribe expensive treatments, in order to recoup more from insurance companies. Insurance companies in turn reduce reimbursements, decline treatments, and remove people from coverage in order to maximize profit by limiting what they will pay for.

          Health savings accounts can help provide some cushion for expenses such as monthly prescriptions, office visits, etc. But there are significant drawbacks as well. Young people typically don’t the kind of money necessary to set aside lots for potential medical expenses down the road, what with college debt, saving for a home, paying for children, etc.

          I’ve found this “back of the napkin” summary of the health insurance debate to be very illustrative of the issues at hand.

          And this chart makes it easy to see that the “public option” proposed in several versions of health insurance reform legislation is a small – but very important – part of the plan to improve coverage and lower costs.

  2. Walt says:

    Sorry I’m not buying your argument that single payer will insure what ever it is 30 or 47 million more people, lower cost and still provide the same benefits. Does a single payer take into account behavior risk? People in the US do a lot of things that affect their overall health and shouldn’t they be charged accordingly? After all if people don’t pay more for smoking, having a high BMI or doing drugs where the incentive to ever change? Comparing the US to other countries is like having only one tool in your tool box( a hammer) and everything starts to look like a nail.

    Have you noticed how many young people have the latest cell phone technology? 24/7 web access with plans that range maybe $50.00 per month. It’s really about setting priorities instead of buying into this culture of having the latest greatest expensive stuff.

    If young people would put that money into HSA’s instead, they would build up a nest egg of health care when they do need it in their older years. This is just like our investments for retiring unless you think social security will take care of all of us and meet our needs.

    In the business world, we sell widgets and widgets sales are based on demand, replacement cost and COMPETITION. In markets where we have little or no competition, we can make large margins and profits until more players enter and we are forced to readjust our prices. This is what needs to happen to health reform and government is not a fair competitor.

    • I’m going to let the words of U.S. Rep. Anthony Weiner (D-New York, 9th District) respond to your points about single payer and competition:

      [T]he United States already uses single-payer systems to cover over 47% of all medical bills through Medicare, Medicaid, the Veterans Administration, the Department of Defense and the Bureau of Indian Affairs.

      These institutions also provide health care to millions of satisfied customers in every community who would heartily agree that the government can build and run programs that work quite well.

      If Medicare has been such a success, why not extend it? Why not have single-payer plans for 55 year olds? Why not have one for young citizens who just left their parents or college coverage?

      Americans would still go to the same doctor and the same neighborhood hospital. Sure, they would be able to delete the 1-800 number of their insurance company from their cell phones. And doctors would have to get rid of all those file cabinets full of paperwork while their assistants who spend time fighting with insurance companies would be able to actually speak to patients.

      But everyone would adjust, I’m sure.

      If Wal-Mart can pool its customers to be able to offer the $4 prescriptions, why shouldn’t the federal government drive the same hard bargain on behalf of the tax payers so they too get the best prices under Medicare?

      As for HSAs, people young *and* old need health insurance coverage. I’ll give you a personal example: when a recent bike crash sent my younger brother to the emergency room with a broken collarbone, the bill came to $15,000 — not including the ambulance ride or subsequent visits to an orthopedist. His portion (under the “catastrophic” coverage he has) was $3000. The birth of his son a few years ago set him back even more.

      And my brother — like millions of other small business owners — actually needs his cell phone to stay in touch with his business clients, so suspending his cell phone plan and home internet to pay for those medical costs isn’t a realistic option if he wants to keep earning a living.

      Under the totally private, for-profit system you propose, health insurance companies would race to enroll young and healthy (i.e., profitable) people into their health plans, while charging exorbitant rates for coverage of old and sick (i.e., expensive) people — because that’s what’s profitable.

      It’s one thing to sell widgets or car insurance for profit. But individual and public health — in other words, our quality of life — is too important to be left to the machinations of the marketplace.

      • Mark says:

        How can you possibly call Medicare a success when it’s completely insolvent? It’s predicted to go broke within a decade, and the cost of keeping it running in its present state afterwords is projected to cost tens of TRILLIONS of dollars. When the government is forced to seriously reduce benefits, then ask those seniors about the program that “works quite well.” But knowing today’s politicians, they’ll probably just resort to higher taxes or printing money to fill in the gap, screwing everyone over.

        • Mark, Medicare’s success lies in keeping administrative costs very low (see here for an apples-to-apples comparison) while keeping patients healthy – and happy with their coverage, as recent polls show. Rising health care costs are straining Medicare’s finances – but that isn’t Medicare’s fault. Last year, in fact, the United States spent $2.3 trillion on health care—$7,681 per person, a far larger per-person cost than in western European nations where everyone actually gets health coverage (unlike the 47 million Americans here who don’t). Without Medicare, our nation’s health care costs would be even higher than they are now.

  3. David says:

    We are already paying for the health care (and “insurance”) of the uninsured when they go to the ER for emergent or even routine care. Yes, many uninsured go the county hospital ER for routine care because it is free and they can’t get an appointment in the overburdened clinics. It is immoral and illegal in our society to deny urgent life saving care to anyone who shows up in our ERs. Our religious institutions no longer provide free care. We do with our taxes already! Even insured people, when they blow through their insurance maximums and then their life savings will often end up on public aid. Again, we end up paying with our tax dollars already! Why not cut the huge administrative costs of having the countless inusurers, staff and paperwork of our current systems and save more money in a moral single payer plan?! We are already rationing care by excluding the uninsured and by insurance companies excluding certain procedures. Rationing is inevitable. Let’s do it fairly and rationally already!
    As for “competition”, health care does not follow the usual rules of business for the moral and practical reasons above. The more care that is provided, the more the demand. Even if I am uninsured, you are going to pay when I crash my car or develop an intractable disease through no fault of my own if I go to the public hospital. Our economy and our people are suffering already.

    I think cries of “free markets” and “don’t let them sociallize health care” are usually shouted by the insured who fear losing their elite benefits and feel the need to justify an unfair system.

  4. Walt says:

    Call me crazy but I always understood insurance to be about measuring risk. From the moment I started driving I clearly understood if I had accidents or multiple speeding tickets I would pay higher premiums because it would most likely cost the insurance company more. Health care needs to have the same incentives such as rewarding people with lower cost who don’t smoke, drink too much and get regular exercise.

    With an HSA, you have to take personal responsibility because you manage the withholding and payment. If you demand a lot of care, you have to plan ahead and make sure enough is coming out of each paycheck to cover your future medical expenses. To wait until you have a serious medical issue is like waiting until you have an accident in your car to decide to buy auto insurance. Yes people with preexisting conditions should be covered but they should pay higher premiums because they use and demand more services. How much should be dependent on their income and health situation.

    Everyone gets life saving emergency treatment even if they don’t have insurance. Everyone knows this, that’s why so many people simply won’t buy insurance. Basically we reinforced this type of irresponsibility through our culture by claiming it to be a right. My wife works with many lower income families that use city services. Most are supposed to pay a small percentage of the services they receive but many refuse to even when they can afford cell phones.

    I don’t know why people are so afraid of real competition by allowing Insurance companies to compete against state lines? Ask yourself what your state would look like if you could only purchase products produced in your state. Health care is a product of goods and services and like anything else, people have to get paid or nothing happens.

    Of course the Insurance companies don’t want real competition, they want a limited market provide by the government where there is not enough pressure to lower cost. Sorry but Government is NOT fair competition. There is no incentive to lower cost or deliver better services because they can’t go out of business. They simply rely on the tax payer for more money when they need it. This is horribly inefficient.

    The President says if we like our health care we can keep it. What the President doesn’t tell us is that for the vast majority of us, these decisions are not made by us but by our employers. I suspect many companies would gladly turn our health care over a subsidized government plan to save money and all the hassle of administrating it.

    The real dilemma I see shaping our future is health technology quickly outpacing our ability or willingness to pay for it.

    • David says:

      What choice do we have now about whether health care is a right or not? Sure, some people choose a new cell phone over building up their HSA accounts. But many millions of people do not have savings, money market, or even checking accounts. They live paycheck to paycheck. We can say they have to pay more if they smoke or drink alcohol but you can’t wring blood from a stone. When they carry the flu or Tuberculosis and live next door to you or sit next to your child in a movie theater, you have a right to them having health care. Indeed, the government can force them to receive care or be isolated. So, health care is not just another product of goods and services. Everyone collectively needs everyone to be covered in the most efficient way. The only way to do it is the way every other developed country has chosen to do it (albeit imperfectly). Comparing the US to other countries is a logical and practical thing to do. In doing so it is not that we only have a hammer and see everything as a nail. Its that all human societies face illness and death with limited resources. Why not learn from others’ experience? Clearly our system is not working, is immoral and is more expensive to administer than others. It is dragging down our economy and bankrupting plenty of perfectly law abiding, thin, nonsmokers who happen to develop illnesses that are very expensive to treat and “not covered” by their insurance. Of course, there are those who overeat or smoke and drive up health care costs. Real disincentives like cigarette taxes help curb smoking. HSA accounts, (which I see as a clever way of big businesses diverting worker’s attention from the underlying problem by offering the illusion of tax saving security for the employed), often are exhausted when serious illness hits. HSAs are only valuable to those citizens who earn enough to care about tax free savings. Very ill people are not in that group. Very ill people need help from the larger number of mostly healthy citizens. That way, when you or your loved one falls ill, he is cared for humanely. That is part of the social contract. When you are very very ill, you should not have to shop, analyze, compare, bargain, pre-approve, and negotiate your care. Even on a good day, calling insurance companies to get accurate details on coverage is time consuming and frustrating. I, as a physician, would much prefer knowing that I would get care if needed, and that I would get paid when providing services, even if it is less than I can earn now. We should not profit from the health troubles of others. Health care is not like other businesses. It is a practice and a calling and a responsibility and a right.

    • I think that from the insurer’s point of view, the process is indeed about measuring/allocating risk and charging accordingly. From the patient’s and the doctor’s, it is about getting the right treatment at the right time, in order to get and/or stay healthy.

      Clearly, there are individual factors of choice that influence certain health risks, as you’ve outlined. But there are genetic and environmental factors as well, which are clearly outside any one individual’s ability to influence. So we need a health care system that educates people about healthy choice and encourages them to make smarter decisions — but it also has to be there to help us get well when, despite those choices, we get sick anyway.

      The question that comes to mind for me is: What, exactly, is a “pre-existing condition”?

      Say a baby is born with a heart defect. Not the baby’s fault, not the parents, certainly not the doctor’s. Should that person later be denied coverage when they turn 18 and try to enroll in a health insurance plan? Or should they pay a higher premium for the rest of their life? From a purely “risk management” point of view of that individual health insurance company, yes – that person could hurt the bottom line. But not from society’s point of view. If that person goes without coverage because they can’t afford that higher premium, we all have to pay more later when they end up in a very expensive emergency room. You say they would pay less for their premium if they couldn’t afford it – who is going to subsidize them?

      Another example: a couple decides to get pregnant. After they’ve conceived, one of them loses their job – but manages to find another. Should the wife be denied health coverage when they attempt to enroll in a different health plan? Again, the health insurance company knows she will cost them money, so they don’t want to enroll her. But we in society know that getting that child the proper pre- and post-natal care is going to be a lot cheaper – and a lot better for all of us in the long run. We need that kid to grow up and be a successful contributing member of society, pay taxes, etc. That’s hard to do without good medical care.

      Think about what a world where people have only health savings accounts to rely on would really be like. At any time, you could be hit with a bill for thousands of dollars worth of medical treatment. If you’re lucky enough to earn enough money, you’ll save it. You won’t spend it to go to college, start a business, or buy a house, or do any number of other things that are better for you (and society) from an economic point of view. Literally millions of dollars would be tied up in HSAs, just sitting there, waiting for people to get sick.

      The odds of any one person needing that money are low. But if your number does come up, you need a lot of it. So instead of having all that unused money sitting in individual accounts, how about we each contribute a little bit to a shared pool? Call it a “shared health savings plan”, if you like. Healthy people, sick people, young, old – we all put in a little bit, and since only a relatively few people get sick at a time, there’s enough money to cover those costs. We can all take the rest of the money we would have saved “just in case” and put it to better use.

      It makes a heckuva lot more sense to pool our risk together, rather than take it on individually. And the bigger the risk pool, the better it is for all of us, because less money is needed from each individual. In fact, the most efficient risk pool of all would be putting the entire country into one big pool. Big risk pools are how the Medicare works that my dad gets, and how TriCare works for our nation’s armed forces.

      Now, I’ve got push back a bit on your point that “Everyone gets life saving emergency treatment even if they don’t have insurance. Everyone knows this, that’s why so many people simply won’t buy insurance.” Seriously? You think if you gave everyone in an ER who was there because they had no insurance the choice of a) an inexpensive insurance plan that let’s them make an appointment to see their very own doctor, and b) an outrageously expensive service where you have to wait for hours to be seen, people would really choose the latter? I’m sorry, but that just doesn’t pass the red-face test.

      When it comes to insurance, providers want to keep costs low and revenue high. The best way to do that is to insure healthy people who won’t make claims, and deny claims whenever possible. That’s fine for making money, but not so great for keeping people healthy, or for keeping costs down for the rest of us. When it comes to health care, competition = fractured markets = smaller risk pools = higher costs for all concerned. You can see that now in the existing market. Between 1997 and 2006, health spending per enrollee (for comparable benefits) grew at 4.6 percent a year under Medicare, compared with 7.3 percent a year under private health insurance. (More: http://institute.ourfuture.org/files/Jacob_Hacker_Public_Plan_Choice.pdf)

      A government you vote on every two years is going to be much more accountable to you about the money they spend than the board of directors of a private company that is spending your premiums. And the health insurance reform proposals on the table aren’t about the government providing health services – they’re about government paying for them, and using economies of scale to drive down costs. In the best of all worlds, we would do that by simply expanding Medicare to cover all citizens. Everyone’s covered, and under a progressive income tax system, people who can afford to pay more for it do so, over their lifetime. Those who can’t, don’t.

      Will we still face tough choices about technology and our willingness to pay? You bet. But that’s the case regardless. And under “Medicare for all”, at least we would pay less than we do now.

  5. Walt says:

    Aaron, I’ like to reply to your comments. Lets take this one by one.

    1st scenario, baby born with heart defect. Note I indicated “should be dependent on their income and health situation.” Why should someone be forced to subsidize someone else’s care that is already making more then they are? Yes there is role for Government to play here but you don’t create everyone’s plan based on the exception. You can have more then a hammer in your tool box. Should people who are obese and refuse to exercise pay more? Of course.

    2nd scenario; here is a perfect example why we should own our own health care plan that is portable and not dependent on our employers. Even if one spouse lost their job or took a leave of absence as many mothers do, you still have control of your health care. Having grown up poor myself, somehow my wife and I were able to make these decisions ourselves. On very limited income we managed to pay our health care insurance, send our kids to private schools and even fund their college education. This certainly wasn’t easy as we went without a lot for so many years. Right now we’re in the saving mode of putting more money into our 401k’s for future retirement.

    I didn’t fully explain my own managed health care very well. I use my HSA for everyday or regular health care expenses. If I manage these efficiently and not run to the doctor for every little small annoyance, the money pools and grows for future use. You decide how much to put away out of each paycheck. I also have a “high deductible” plan that covers the major expenses if needed. Part of the plan also involves a “wellness” program where you have blood pressure and blood work done every year, don’t smoke, complete a physical on an annual basis, 2 dental check ups and “regular” exercise. If one turns down the wellness plan, they’ll still get covered but they pay more as logic dictates they’ll most likely need more health benefits. Our plan is very similar to Whole Foods health care plan in that makes a lot of sense and goes a long way in holding health care cost down and makes people think and act more responsibly.
    http://online.wsj.com/article/SB100014A government you vote on every two years is going to be much more accountable to you about the money they spend than the board of directors of a private company that is spending your premiums24052970204251404574342170072865070.html

    I have no problem creating a plan like a “shared health savings plan” as long as individuals have the choice to participate or not. Let a million private plans flourish and let the best and most efficient ones succeed. But note we won’t have choice under a Government that threatens people with jail or heavy penalty if they don’t carry insurance.
    The President says there’s a $1,000 hidden tax that all families pay for those that don’t carry health insurance. We’ll if that’s the case then pass the plan and send everyone that has been carrying insurance a check for $1,000. Bet it would pass then.
    http://blogs.abcnews.com/politicalpunch/2009/11/interview-with-the-president-jail-time-for-those-without-health-care-insurance/comments/page/2/

    I never claimed anything about “cost” on the fact people using the emergency rooms. What I said was people know that treatment cannot be denied. Yes the cost will have to be absorbed by others that have insurance. I think we can all agree to this fact. But the other fact is we already have programs that help lower income people maintain their health and not all but some act as if this is a “right” and no they shouldn’t pay even a measly co-pay. My wife see’s this all the time. It’s a dangerous attitude because it absolves people of their own responsibility. Now there’s something to be outraged about.

    Even the President has made statements that we need more competition in health care. Probably something else we can agree on but the problem is the President thinks Government is a fair competitor to the private market. Governments make the rules and can easily tilt things in their favor (kind of like the house in Vegas). Because they can be funded with taxpayer money, there is no incentive to run efficiently. Ever heard of cars for clunkers program? Would you call that an example of efficiency? http://money.cnn.com/2009/10/28/autos/clunkers_analysis/

    You wrote“A government you vote on every two years is going to be much more accountable to you about the money they spend than the board of directors of a private company that is spending your premiums.”

    Sorry but that just doesn’t pass the “red face test.”
    Ask some people living under some of these plans right now.
    http://www.city-journal.org/html/17_3_canadian_healthcare.html

    Take Care,

    Walt

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