CONTACT:Ben PalmquistNational Economic and Social Rights Initiative
(212) 253-1710 ext. 304, ben (at) nesri.org
Friday, February 26 Senator Bernie Sanders proposal for universal, publicly financed, single payer health care has prompted a raucous public debate among economists.
The debate rose to a crescendo last week when four former heads of the Council of Economic Advisors (CEA) and economist and New York Times columnist Paul Krugman lashed out at Sanders and economist Gerald Friedman (a Hillary Clinton supporter who conducted an independent analysis of Sanders health care plan) in what many are calling a dishonest political attack.
The four CEA chiefs criticized Friedman for making extreme claims based on no credible economic research, and Krugman followed suit with a stinging column calling Friedmans work horrifying, embarrassing, and voodoo. Their criticism focused on skepticism of Friedmans projection that universal health care and other public stimulus programs would induce the economy to grow significantly in the coming years.
As soon as the five economists lashed out, other economists rushed in to defend the integrity of Friedmans work, calling out the five economists for what they saw as an attempt to smear Friedman and Sanders, and pointing out that they had done no rigorous economic analysis on which to base their claims. A number of economists are urging serious exploration of publicly financed universal health care, arguing that such a system would be more sensible, pragmatic and ethical that the current for-profit insurance system.
James Galbraith, a former Executive Director of the Joint Economic Committee, wrote an open letter to the CEA chiefs calling their accusations not fair or honest. Galbraith continues, What the Friedman paper shows is that under conventional assumptions, the projected impact of Senator Sanders' proposals stems from their scale and ambition. When you dare to do big things, big results should be expected. The Sanders program is big, and when you run it through a standard model, you get a big result.
Ron Baiman, an economist at Benedictine University, wrote on his blog that the CEAs appear to believe that their status entitles them to a blanket dismissal, without a shred of argument or analysis, of a standard economic analysis of a raft of economic proposals the scale and scope of which have not been seen since the New Deal.
Dean Baker, co-director of the Center for Economic and Policy Research, says, It is understandable that those opposed to Senator Sanders candidacy would want to belittle his health care proposal, but it would be more helpful in advancing health care policy if we could have a serious discussion of why the U.S. health care system costs twice as much per person as the average among other wealthy countries.
A number of economists have pointed to the high costs and inefficiencies inherent to the for-profit insurance system.
Katherine Moss, Economist and Visiting Faculty at Sarah Lawrence College, says, It is well known that the U.S. health care system is fragmented, costly and inefficient. Single payer, publicly funded health care would expand access while reducing wasteful and excessive spending.
Patrick Mason, an economist at Florida State University, says that for-profit employer-sponsored insurance is an inefficient and costly approach to providing health insurance. He points out that a publicly provided national health care program would be much more efficient that the current system both because it would considerably lower administrative costs and because by expanding health care access to everyone, it would create a healthier population with fewer costly illnesses.
Robert Chernomas, Professor of Economics at the University of Manitoba, says, The US has by far the most expensive health care system in the world, the worst health indicators among wealthy industrialized nations and is the only industrialized nation without some form of truly universal health care. The overwhelming findings of the New England Journal of Medicine, the Journal of the American Medical Association, the Canadian Medical Association Journal and the Harvard School of Public Health is that private, for-profit health care is more costly, of lower quality, provides lower patient satisfaction and has a higher mortality rate than not-for profit health care.
Chernomas asks, Why spend $1.50 on inefficient private health insurance, ineffective and more costly for-profit hospitals and a poorly regulated pharmaceutical industry when for $1 or $1.10 you can get higher quality universally accessible health care paid from taxes and protected by democratically elected governments?
Other economists argue that because health care is not only part of the economy, but also a fundamental human right, universal, publicly financed health care is both good economics and a moral issue.
Mark Paul, a PhD candidate in the Department of Economics at the University of Massachusetts Amherst says, The current health care system is based off bad economics. Single payer health care in the United States can save billions of dollars. Not only are the economic numbers in favor of a single-payer system, but more importantly, it would save lives.
Terrence McDonough, an economist at the National University of Ireland Galway, says, Universal single payer health insurance is the only way forward for the United States health care system. Health care is a human right and should not be rationed according to ability to pay. For this reason universal coverage is the only ethical option.
A number of economists contend that the reason there has been so much resistance to a policy that would both cost less and produce better health outcomes is that powerful health care companies have overwhelmed the political process.
Jose A. Tapia, an economist at Drexel University, says, The only explanation of this absurd situation is the strength of the forces opposed to single payer national health care. Huge private and public costs of health care in the United States flow into enormous profits for those companies and individuals who benefit from the health care business.
Paddy Quick, Professor of Economics at St. Francis College in Brooklyn, says, The need for a fundamental restructuring of the health care system of the United States is clear. The opposition comes from the many insurance, pharmaceutical and other health-related corporations (as well as the many so-called non-profit institutions) who profit from the current system. In this they are supported by those whose income enables them to purchase the best that money can buy.
Yavuz Yasar, Associate Professor at the University of Denver, says, What makes the single payer plan radical is the existing wasteful, outrageously expensive and inefficient U.S. health care system that helps health insurance firms, pharmaceutical companies and providers to increase their profits at the expense of we the people.
Baiman too sees the current debate as more a political debate than an economic one. No one assumes that Bernies economic program will be passed as currently conceived. The fate of these proposals depends on the power of the political revolution that the Sanders campaign is leading. This is not a technocratic economic debate. Its a political and ideological debate.
At first blush, many Americans like the idea of Medicare for all, the government-run health system thats a rallying cry for Democratic presidential candidate Bernie Sanders.
But mention some of the trade-offs from higher taxes to giving up employer coverage and support starts to shrivel.
Comment by Don McCanne of PNHP: Most polls place support for a single payer Medicare-for-all national health program at about 60%, with some variation based on labels, framing, and polling technique. Yesterdays Kaiser poll placed it at 50%. This new Associated Press GfK poll places it at about 40%, but it is unusual in that over one-fourth of those polled expressed no preference. Of those expressing a preference, 54% were supportive and 46% opposed. But there was something else that was also very unusual about this poll.
Yesterdays Kaiser poll demonstrated that the views on single payer were malleable. When asked about negative features that allegedly are associated with single payer, support declined, whereas support increased when asked about positive features. In this AP-GfK poll they were asked only about allegedly negative features, and support declined. But what were these negative features?
* Your own taxes would increase - But no mention was made of the savings in premiums, out-of-pocket expenses and other taxes that would more than offset the new taxes, resulting in a net savings.
* Some people needed to switch doctors - But that is a characteristic of private plans with their narrow networks whereas single payer provides free choice of health care professionals.
* It took longer for new drugs and treatments to become available - There is no way that the pharmaceutical industry is going to walk away from a $3 trillion market.
* Longer wait times for nonemergency medical services - Responsible stewards would use capacity adjustment and queue management to prevent excessive queues, as has been done successfully in several other nations.
* People needed to give up other coverage like employer coverage - But they would be trading that for a superior program with more comprehensive coverage, reduced out-of-pocket costs and greater choices in health care.
* The new system would replace Medicare for seniors - Who would want to continue with the current Medicare program that pays for only about half of health care when you could have an improved Medicare with more generous benefits?
Why would the Associated Press conduct such a deceptive poll at a risk of impairing its credibility? When you read the AP release, you cant help but come to the conclusion that it was designed to slam presidential candidate Sen. Bernie Sanders and his support of Medicare for all. They even included a gratuitous comment from an unemployed office manager to the effect that the single payer system is subpar like in Europe and Canada - an absolute falsehood.
Whatever the intentions of the Associated Press, we must make every effort to dispel the deceptions and disseminate the true facts about single payer Improved Medicare for All. The health of America is at stake.
While Clinton's spokesperson told PULSE that she has consistently backed the public option since the 2008 campaign, Clinton pointed out just last month that Congress wasn't able to get it through during the ACA. "There was an opportunity to vote for what was called the public option," Clinton said during a debate in South Carolina, after she rebuked Sanders' plan as impractical. "But even when the Democrats were in charge of Congress, we couldn't get the votes for that."
Continue to support a public option and work to build on the Affordable Care Act to make it possible. As she did in her 2008 campaign health plan, and consistently since then, Hillary supports a public option to reduce costs and broaden the choices of insurance coverage for every American. To make immediate progress toward that goal, Hillary will work with interested governors, using current flexibility under the Affordable Care Act, to empower states to establish a public option choice.
PNHP doesnt't like it, but I think it's still worth pursuing.
A quarter century of experience with public/private competition in the Medicare program demonstrates that the private plans will not allow a level playing field. Despite strict regulation, private insurers have successfully cherry picked healthier seniors, and have exploited regional health spending differences to their advantage. They have progressively undermined the public plan which started as the single payer for seniors and has now become a funding mechanism for HMOs and a place to dump the unprofitably ill. A public plan option does not lead toward single payer, but toward the segregation of patients, with profitable ones in private plans and unprofitable ones in the public plan.
Comment by Don McCanne of PNHP: You remember the public option. During the drafting of the Affordable Care Act (ACA), efforts were made to include a public option - a government-run plan that would compete with the private health plans in the insurance marketplace. If the private plans proved that they could provide greater value, then they would prevail. If the government could do a better job, then the public option could expand by demand and eventually become the single payer for the nation, so supporters believed.
The original concept for the public option was to allow individuals to buy into the Medicare program instead of purchasing private insurance. There were some obvious problems. Medicare lacked some important features required of the private plans such as catastrophic coverage - establishing a maximum out-of-pocket responsibility of paying for health care. Also, the existing Medicare pool was composed of the elderly and those with long term disabilities - expensive groups to insure. The exorbitant premium that would have to be charged could not be competitive with the private plans.
It was then decided to establish a new public insurance program that was designed like the private plans and that would have to follow the same rules. The insurance industry immediately opposed this since it would be unfair competition considering the government resources backing up the public plan, and the inherently higher administrative costs that the private insurers face, not to mention the need to profit from their operations - profit not being a feature of a publicly-owned insurer. Several (anti-competitive) features were proposed for the public option which would give the private insurers a fair playing field.
The insurers were still concerned that they could not compete against even a restricted government plan, and thus they continued to oppose it. There is a basis for that concern since the private Medicare Advantage plans are able to compete with the traditional Medicare program only because of the overpayments that are being made to the private plans. If they were in the same playing field, the private plans would perish. Nevertheless, the issue of the private option became moot when Sen. Joseph Lieberman, with no votes to spare, threatened to kill the entire Affordable Care Act if the public option were included.
We were left with the co-ops as a substitute for the public option. The co-ops are non-profit organizations in which the insured members are the owners. Congress, under the Republicans, has refused to provide promised funds, and half of them have collapsed. They are now being used by opponents of single payer to prove that the government would be incapable of running a single payer system - an obvious non sequitur.
Since the enactment of ACA there have been endless calls to add a public option. Single payer failed to gain traction because of the pervasive meme that single payer was not politically feasible. But if we could just get a public option, that would automatically evolve into a single payer system, they said.
Then along came Bernie Sanders. He carried the message that not only was single payer politically feasible, it was a moral imperative to achieve health care justice for all. To the surprise of Hillary Clinton and her campaign staff, Bernie Sanders came out of nowhere and gained traction carrying the single payer banner, and, as a result, has become a genuine challenge to her candidacy.
Hillary Clinton has always been an opponent of single payer and instead has supported the private insurance industry. Some have misinterpreted a statement of hers many years ago as supporting the fact that we would have single payer in the United States. But that statement was not in support of single payer but rather was her threat to us that if we did not accept her managed competition model of reform, we would have single payer.
So what was her campaign to do? They decided to bring back the concept of a public option to appease those who were turning to Sanders because of his advocacy of single payer. They are relying on the meme that the public option is our door to single payer (even though it is not true). But look at what her version of the public option is.
She says we should build on ACA. She has proposed no new federal public option legislation but she is merely suggesting that the states look at Sec 1332 of ACA which authorizes waivers for limited innovations on a state level. Imagine the difficulties that states would have, within the confines of Sec 1332, in building their own intra-state public plan. Unless they used private insurance innovations such as high deductibles, narrow provider networks, and tiered services, the premiums would be unaffordable to most. A single payer system would be funded equitably through progressive taxes, but you could not do that with a public option since that is only one plan in a multi-payer system.
In 2009, David Himmelstein and Steffie Woolhandler explained in very brief terms why the public option is a flawed concept (reproduced above). Hillary Clinton is now showing us how it is a diversion from the reform we really need - single payer. It is up to us, the people, to convince our politicians that single payer is what we want. It will not happen without us.
Hospitals are feeling the pressure from those patients. Community Health Systems Inc. operates 195 hospitals in 29 states and is the U.S.s second-biggest for-profit U.S. hospital chain. This month, it revised its fourth-quarter 2015 provision for bad debt up by $169 million -- and said that 40 percent, or about $68 million of that amount, was from patients being unable to pay deductibles and co-payments. Patient bankruptcies also contributed, the company said.
While higher out-of-pocket charges can lower what insurance costs up front, it means more costs for patients on the back end. Under individual Obamacare mid-level silver plans, the annual deductible was $2,556, and under less expensive, low-level bronze plans it was $5,328 in 2015, according to the Kaiser Family Foundation.
Outside of Obamacare, deductibles are becoming more common, as well. Last year, 81 percent of coverage people got through work came with a deductible, up from 70 percent in 2010, according to Kaiser. The average deductible in a high-deductible, individual plan gained through work was $2,099 last year.
Rural hospitals have been hit particularly hard. Minnesota has long had high rates of care coverage, and many employers have switched to high deductible offerings, according to Joe Schindler, vice president of finance for the Minnesota Hospital Association. Last year, bad debt rose by 20 percent to $425 million at the associations 140 member hospitals.
Comment by Don McCanne of PNHP: The Affordable Care Act (ACA) was supposed to make health care affordable, yet many hospitals are finding that patients are generating more bad debt. A large portion of that is due to the inability of patients to pay the high deductibles and other cost sharing required by their insurance plans. Patient bankruptcies also compound the problem.
Deductibles are used by insurers to shift some of the spending to patients so that the insurers can keep the premiums for their plans competitive. But much has been written about how these deductibles create financial burdens for patients. And when the patients cannot pay the deductibles, physicians and hospitals are faced with bad debt. With greater use of higher deductibles, the problems with debt will surely increase.
This is a problem inherent in the model of reform perpetuated by ACA. Various policies such as the deductibles are developed to comply with the private insurance model. How would the incrementalists fix this problem? There are too many moving levers.
What we should have instead is a system in which the policies are developed to comply with the needs of patients. Deductibles can be eliminated if we do away with premiums as a means of financing health care.
The financing of a single payer system is not through individual premiums but rather is through a single universal risk pool that is funded equitably through progressive taxes, making health care affordable for everyone. Medical debt simply goes away.
For example, Indiana is testing whether requiring participants to make monthly contributions to a health account that can be rolled over if not used for health care reduces the use of unnecessary care.
That feature is based on high-deductible insurance plans with health savings accounts that are becoming increasingly common in private insurance coverage.
Pence argues that the Urban Institute, one of the evaluators chosen by the federal government to assess Indianas plan, has previously been skeptical of using the health savings account model for Medicaid recipients.
Pence wrote Health and Human Services Secretary Sylvia Burwell in December, asking that the federal review be dropped as the Healthy Indiana Plan has already been evaluated by a state-hired contractor.
The RWJF/Urban Institute report that Pence argues shows a bias against using healthy savings accounts in Medicaid:
Comment by Don McCanne of PNHP: Gov. Mike Pence of Indiana wants to select his own facts for a report to CMS confirming that their consumer-directed health program for Medicaid, authorized by a Sec. 1115 waiver, is meeting Medicaid requirements for the patients.
They have already independently contracted with the Lewin Group to provide a report to CMS, but numerous organizations have expressed the concern that this report could be biased because of the conflict of interest. CMS has contracted with the Urban Institute, but Gov. Pence objects because Urban has produced a previous report expressing some concerns about the option to charge premiums for individuals living in poverty and about the administrative costs and inefficiencies of health savings accounts that are used in Indianas program. Also there is concern about Medicaid patients being locked out of care if they are in arrears with their premium payments.
Indianas program is driven by ideology rather than by objective application of health policy principles. Pence touts their success at applying consumer-health care principles to the Medicaid population. It is more important for him to require patients to demonstrate individual responsibility through sharing in the costs of care than it is to ensure that they do receive the care that they need. It has been demonstrated that requiring payments creates barriers to care, particularly for low-income individuals.
Imagine instead having one national standard program that automatically includes everyone, gives them free choice of their health care professionals, and removes financial barriers to care. We could have that with a single payer national health program, as long as we keep ideologues like Pence out of the way.
Yesterday The New York Times ran an article trotting out elites two favorite narratives. Both are incredibly disingenuous, and say more about the political agendas of the people spreading the narratives than they do about health care.
The first narrative is that publicly financed health care is economically infeasible. The Times cites a grand total of just three economists who question the costs laid out in Sanders health care plan. The three economists the Times cited are absolutely overwhelmed by the 106 U.S.-based economists who signed an open letter last year in support of public health care financing. That letter stated, As economists, we understand that universal, publicly financed health care is not only economically feasible but highly preferable to a fragmented market-based insurance system. We support publicly and equitably financed health care at federal and state level.
If elites are arguing that no president could muscle through legislation for truly universal health care, theyre absolutely right, but theyre missing the point. This isnt about Sanders or other politicians. Enacting truly universal health care means changing whats politically possible, and that takes a social movement. It was organizing by workers, women, African Americans and others that brought us womens suffrage, the 40-hour work week, Social Security, Medicare, Medicaid and the Civil Rights Act, and theres reason to believe we are on the brink of major social changes again. Look around. People are fed up, and movements are growing.
The infeasibility narratives pushed by The New York Times and other elites say much less about health care than they do about elites agendas and the incredible historical moment we are living through. For decades, weve all been told that if we work hard, well succeed. But millions of people are struggling in a very real way, and arent buying the myth of trickle-down economics anymore. Lets not let a small cadre of political and media elites scare us into accepting the way things are. Lets stand up for universal publicly, financed health care not only because its sensible, but because its right.
Hillary Clinton and others charge that Bernie Sanders' Medicare-for-All plan would disrupt and threaten Americans' health care. But the smooth rollout of Medicare-for-Seniors in 1965 -- which many had also predicted would bring chaos -- belies that charge.
Medicare, signed into law on July 30, 1965, went live just 11 months later. By then, 18.9 million seniors had signed up, 99 percent of those eligible.
To accomplish this feat (largely without computers) the Social Security Administration mailed an information leaflet and sign-up cards preprinted with each individual's name and Social Security number (see example below) to seniors on the Social Security and railroad retirement rolls, as well as Civil Service annuitants and a million other seniors identified through IRS records.
Hundreds of thousands of people lose subsidies under the health law, or even their policies, when they get tangled in a web of paperwork problems involving income, citizenship and taxes.
Some are dealing with serious illnesses like cancer. Advocates fear the problems, if left unresolved, could undermine the nation's historic gains in health insurance.
The government says about 470,000 people had coverage terminated through Sept. 30 last year because of unresolved documentation issues involving citizenship and immigration. During the same time, more than 1 million households had their financial assistance "adjusted" because of income discrepancies. Advocates say "adjusted" usually means the subsidies get eliminated.
"When people get that bill for a full-price plan, they panic and they cancel the insurance," said Elizabeth Colvin of Foundation Communities, an Austin nonprofit that serves low-income people. Some worry the problem could undermine the law's insurance markets, now in their third year.
In 2010, the non-partisan Rand Corporation estimated 27 million people would have exchange policies this year and the Congressional Budget Office at that time was estimating 21 million
or 2016. CBO even said last June that 20 million people would have plans purchased on the exchanges this year. Just 12.7 million signed up for plans, however, by the end of open enrollment Jan. 31 and about 1 million people are expected to drop their plans or be dropped when they don't pay their premiums.
Comment by Don McCanne of PNHP: Participation in the ACA exchanges is coming in at a much lower level than were the original predictions. Furthermore, significant numbers drop out each year, and many find that they receive significantly less financial assistance than they expected at enrollment.
Since the exchanges are not working as hoped, perhaps we need incremental innovations that would improve their functioning - you know, those incremental improvements some politicians and policy wonks keep telling us is all that we need to make ACA a universal, affordable system.
But what incremental change would expand coverage to absolutely everyone? What incremental change would make the plans affordable for everyone? What incremental change would ensure that access to care is affordable when facing very high deductibles? What incremental change would ensure that everyone would remain covered by their plans throughout the year, especially when there are so many different reasons that individuals lose their plans?
As mentioned many times before, the flawed health care financing infrastructure is not amenable to simple incremental patches. Keeping the same infrastructure will only perpetuate the severe deficiencies of our dysfunctional financing model. Many will remain uninsured. Many will not be able to afford health care, even if insured. And, worst of all, many will suffer and die.
Maybe we should start tallying the financial hardship, suffering and death in increments so that we can gradually feed that information to the incrementalists who insist this is a small price to pay for keeping intact the model that protects so well our private insurance industry. Maybe then they will understand the evil of defaulting to incrementalism.
Single payer would fix it.
Can a hospital founded more than 200 years ago to treat the poor also adopt a form of medicine some criticize as health care for the rich?
The answer may come in August, when Massachusetts General Hospital, the third-oldest general hospital in the nation, plans to open a concierge medicine practice.
Based in Boston, the hospital, whose $800 million annual research budget is among the nations biggest, is affiliated with Harvard Medical School and is perennially ranked No. 1 in many categories of U.S. News & World Reports listings of the countrys best hospitals.
Despite its reputation, Mass General as it is known was established in 1811 to care for the citys poor and indigent. Patients in concierge medicine are likely to be anything but that.
The idea of wealthy people paying doctors a retainer for exclusive service is not new. With concierge medicine, which was introduced in the 1990s, patients pay physicians a monthly or annual retainer and expect more personalized care and greater access. A concierge patient who signs up for a practice is not only looking for quality care, they are looking for unfettered access to their provider, said Dr. Michael R. Jaff, the medical director of Mass Generals Center for Specialized Services and a professor at Harvard Medical School.
Comment by Don McCanne of PNHP: Say it isnt true. Mass General? Concierge hospital? Two-tier medicine? Selling the front of the queue to the wealthy?
Is the payment of a bribe to gain better health care access access ethical just because Mass General has given its stamp of approval? They say the money will help support their mission to the community at large, but how does pushing the entire queue back by giving the wealthy a ticket to butt in in front of everyone else help those with low or moderate incomes?
It gives a new meaning to triage. As we organize the delivery of care based on need and urgency, we now have a new paramount guideline, Let the money in first!
Under a more egalitarian single payer system, at least the bribes would not be so flagrant.
Some central Ohio consumers say a Westerville-based health insurer intended to keep quiet about its plan to drop OhioHealth hospitals and doctors from its provider network until it was too late for many of its enrollees to change their health plan.
In those complaints, the consumers, who mostly live in Franklin or Delaware counties, expressed frustration over InHealth Mutuals last-minute notice to consumers about its plan to drop most OhioHealth providers as of March 1.
Many consumers said they were not notified of InHealths plan to narrow its provider network until last week, though some received robocalls on Jan. 30, the day before the deadline to sign up for health insurance through the federally run health-insurance marketplace.
During the first half of January, InHealths leaders decided to drop OhioHealth from the provider network. An official with the Ohio Department of Insurance said that InHealth contacted the department late on Jan. 15, triggering a required 15-day review period during which department officials review documents to ensure that insurance companies clearly explain provider-network changes to consumers.
Comment by Don McCanne of PNHP: One of the more important considerations in selecting plans offered through the healthcare.gov insurance exchanges is whether or not an individuals physicians and hospitals are included in the provider networks selected by the insurer. Although this is supposed to place more control into the hands of the health care consumer, in fact, the insurer is free to change the provider network at any time, yet the patient is prohibited from changing insurers outside of the open enrollment period. Patients lose their providers and cant do anything about it until open enrollment for the next year.
The Affordable Care Act does allow special enrollment periods for unavoidable circumstances wherein a person loses their coverage, but CMS is reducing these special enrollments to prevent patients from supposedly gaming the system. Apparently it is acceptable for insurers to game the system through bait and switch of their provider networks, but Andy Slavitt, the acting CMS administrator, stated that he will not open up enrollment for these victims of bait and switch.
Really, is cracking down on special enrollment periods to the detriment of the patient the type of incremental change we can expect going forward? Great for the insurers, terrible for the patients.
What is wrong here? It is that the model of health care financing that has been foisted on us is one that is designed to take good care of the insurers while treating patients as a necessary nuisance since insurers otherwise would not have a business without them.
Yesterday the citizens of New Hampshire had something to say about a government that takes good care of the wealthy but makes middle- and low-income individuals second class citizens. We have a crying need for a single payer national health program, so it has to be up to us to select politicians who will bring it to us. Most of those currently in office are not going to do it.
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About eridaniMajor policy wonk interests: health care, Social Security/Medicare/Medicaid, election integrity
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