Tag Archives: ACA

Thanks Mr. Trump: Anthem Pulls Out of ACA market

This from Fortune magazine on Anthem’s decision to pull out of the Nevada health insurance exchange:

“In its announcement, Anthem said it had spoken with state leaders and regulators, but the deteriorating market, paired with uncertainty at the federal level, led the company to make a “difficult” decision. The Senate recently failed to make good on the GOP’s years-long campaign promise to repeal the law known as Obamacare, and insurers say Trump has added to instability in the markets with threats to stop paying so-called cost-sharing reduction subsidies.”  (emphasis added)

The administration has several ways to sabotage the Affordable Care Act and failure to support the cost sharing reduction subsidies is one of the prime one.

Thanks Mr. Trump.

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Filed under Health Care, health insurance, nevada health, Nevada politics, Politics

Rest and Repair: ACA and market stabilization

Senator Dean Heller (R-NV) might have wished for a kinder, gentler, headline from the Reno Gazette Journal, but he got this one: “After weeks of waffling, Heller votes ‘yes’ on failed ‘skinny repeal’ of Obamacare.”  Rest assured, he’s promised to work on health insurance reform as part of his duties on the Senate Finance Committee.   This would be as good a time as any for him to demonstrate his knowledge of the insurance sector.

Heller Plays the Bail Out Card: Game One 

Let’s track back a couple of paces in time to review how Senator Heller presented his ‘moderate’ credentials on economic concerns.  While Nevada was in the throes of the Great Recession brought on by the Wall Street Casino machinations, Senator Heller was touting his opposition to the Dodd-Frank Act to insert some common sense regulation of the banking industy, casting it as follows: “Heller mentioned he was the only member of the Nevada delegation to vote against the bank bailout. He called the Dodd-Frank bank regulation bill “cover for those who voted for the bank bailout.”  In short,  that “cover” was the regulation of some of the practices that caused the collapse of the investment banks in the United States.  Senator Heller calculated that the use of the phrase “bailout” would be sufficiently negative to thoroughly obscure his support for the deregulation of the banking sector and the Wall Street Casino players therein.  There’s little reason to doubt he’ll try this play again in 2018.

McConnell Tees Up the Bail Out Card: Game Two

After the “skinny bill” failed, Senate Majority Leader Mitch McConnell provided the framework for the next time Senator Heller might want to play the Bail Out card:

“Now, I think it’s appropriate to ask, what are their ideas? It’ll be interesting to see what they suggest as the way forward. For myself I can say — and I bet I’m pretty safe in saying for most on this side of the aisle — that bailing out insurance companies with no thought of any kind of reform is not something I want to be part of. And I suspect there are not many folks over here that are interested in that. But it’ll be interesting to see what they have in mind.”  (emphasis added)

If Senator Heller didn’t mind obfuscating the purpose of the Dodd Frank Act (by calling it a bail out), he’ll certainly not mind playing the same game with the attempts to improve our health insurance system.  It would be very tempting for him to try this play one more time to cover his opposition to the very proposals that would stabilize the individual health care insurance markets in this country.  For the record, I’m assuming that if a proposal helps an insurance corporation, then Senator Heller will be sure to call it a “bail out.”   Or, in the immortal words of President George W. Bush, “There’s an old saying in Tennessee—I know it’s in Texas, probably in Tennessee—that says, ‘Fool me once, shame on…shame on you. Fool me — you can’t get fooled again.’

Making Mountains from Mole Hills

There are justifiable questions about the stability of the individual health insurance market, but before we launch major proposals in this direction it’s important to note that for all the palaver about the collapse, demise, descent or whatever of the Affordable Care Act, that individual market has been stabilizing on its own.  The Kaiser Family Foundation released its report on this market:

“Large premium increases, typically granted by state regulators, in 2017 contributed to the improved financial performance, as insurers adjusted for a sicker-than-expected risk pool, the analysis finds. However, data on hospitalizations suggest that the risk pool was not getting progressively sicker as of 2017, supporting the notion that the large increases were necessary as a one-time market correction.

Slow growth in claims for medical expenses also played a role in insurers’ financial improvements, according to the analysis.”

So far so good, but there are issues to be faced.

“Although the analysis finds the market is stabilizing, it notes that ongoing uncertainty over payment of cost-sharing subsidies to insurers and enforcement of the individual mandate could lead insurers to leave the market or charge higher premiums in 2018.”

We can now safely assert that when Senator McConnell (and perhaps Senator Heller) speak of “bailing out” insurance companies they may be referring to proposals to provide more certainty to the insurance corporations that the administration will, in fact, make good on those promises to come through with cost-sharing subsidies.  That’s truly stretching the definition of a bail out, but it may prove a highly convenient hook on which to hang Republican rhetoric.

The previous post mentioned the Three R’s — risk adjustment, risk corridors, and reinsurance.  Here’s one proposal for the last on the list:

“Senator Kaine and Senator Tom Carper of Delaware on Wednesday introduced legislation to create a reinsurance program to help insurers offset the cost of covering older, less healthy customers. That type of program—which provides payments to insurers that enroll high-cost individuals—was originally part of Obamacare until it expired last year, and Republican legislators in Minnesota and Alaska have embraced the idea as a way to stabilize insurance markets in those states. “That’s something that should have some bipartisan appeal,” Kaine said. [Atlantic]

Reinsurance was in place until 2016 in order to ease any problems with corporations insuring a high number of risky policy holders, such as those with pre-existing medical conditions.  Re-establishing it would serve the same stabilization purposes today.   The Kaiser Family Foundation provides an explanation of risk adjustment and risk corridors which don’t require an MBA to understand. Neither of these constitute any form of “bail out.”

Conflation Projection 

Conflation is too often a vehicle for obfuscation.  For example, one of the Republican objections to the ACA continues to be the incantation: Socialized Medicine!  There’s no hint of socialized medicine in the ACA, it’s a full bore market based system of encouraging  affordable health insurance policies sold by PRIVATE companies to PRIVATE CONSUMERS for use to pay PRIVATE HEALTH CARE PROVIDERS.  However, this doesn’t prevent Republicans from speculating on the ulterior motives of Democratic advocates of expanding access to affordable health insurance policies.

“Soon, they’ll want a public option!” And, then they’ll want Single Payer…and there you have it Socialized Medicine.

Let’s stop here before the fog gets too thick, and explore other options for improving health care access in another post.

*Thanks to @Karoli and Mark Stufflebeam for suggestions and references. 

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Filed under Health Care, health insurance, Heller, McConnell, Medicare, nevada health, Politics

Rest and Repair: Going Forward With The ACA

Breathe, regroup, and re-enlist in the movement to #Resist the egregious GOP agenda to dismantle the 20th century.  The health insurance bill was the first fight, but it won’t be the last.

First, expect the GOP to repeat ad nauseam all the old talking points about the Affordable Care Act, and to keep working in the background to eliminate key elements of health care assistance, and we need to be prepared to counter them.

“Premiums have skyrocketed”Counter: While there are some states in which premiums for health care insurance have increased dramatically, there are others like Indiana and Rhode Island in which premiums have actually decreased. Nevada’s increase was a modest 8% when compared to pre-ACA rate increases.  [See KFF chart for all 50 states.]  Counter: Premiums are only part of the consumer costs.  If an insurance policy offers low premiums, but includes higher co-payments and deductibles then it really isn’t “cheaper.”

“Democrats want to bail out the Health Insurance Corporations.”  The Republicans used this line when attacking the legislation to get ourselves out of the Great Recession, the product of unfettered financialism on the part of investment banks. This line has served them well, and Senator Dean Heller (R-NV) utilized it almost constantly to impress Nevada voters with his “independence” when bragging about how he voted against “bank bailouts” in the Dodd Frank Act, legislation which applied common sense regulation to investment bank practices.

A much better frame for this argument from the pro-ACA side would be that we want to stabilize the insurance markets.  Including a re-insurance element to the ACA would be helpful.  There is a way to introduce these topics without resorting to protracted arcane discussions about the nuances of the insurance market:  Explain the Three R’s.  Risk Adjustment. Reinsurance. Risk Corridors.

Government is forcing people to buy insurance they don’t want.”  I’m fond of hauling out my auto insurance — even though I’m fully aware of the fact that this is far from a good analogy.  I have one vehicle which works and one that doesn’t.  For the one that works I have a comprehensive policy, and for the one that doesn’t I have a basic policy.  What the ACA does is require a “basic policy.”  The old rig isn’t going to hit anyone or anything unless a tornado picks it up and moves it — but I still have some liability insurance for it. The policy pools all car owners, and basic is basic, so there’s liability insurance on a vehicle that isn’t moving and isn’t going to without a tow truck.  (Please don’t ask why I still have it…the answer is irrational.)

Individual mandates and employer mandates aren’t popular.  That’s fairly irrefutable. However, those mandates are an essential part of creating a widening POOL of policy holders, which in fact serves to help contain health care cost increases.

But everyone has access to health care…in the emergency room.”  No, all this means is that everyone has access to EMERGENCY health treatment, which, as we all know is the most expensive place to receive care.  Further, “having access” is not the same as being able to pay for it — thus the pre-ACA misery of personal bankruptcies and hospitals with disturbing amounts of uncompensated care on their books.

Secondly, have a plan.  A plan to address specific needs for specific problems.  If health care costs are rising faster than other consumer needs, then address this directly.  (1) Allow the government to negotiate prescription drug prices for Medicare the same way the VA negotiates prices for veterans’ medication. (2) Incentivize prescription drug research while limiting excessively high prices.  This sounds impossible, but really isn’t.  A paper from the Brookings Institution (pdf) explains how this might be accomplished.   If about $1 out of every $6 spent on health care is related to prescription drugs, holding the line in this realm would be helpful.  (3) Allow the importation, or re-importation, of medication.  This probably isn’t as efficacious as some of the other proposals, but it, too, could be helpful.

(4) Encourage practices which yield better health care outcomes.  Thus far we have a system which pays for services rendered — as it should — however, efforts to study and promote best practices.  This is a component of the ACA and one that should be publicized more effectively.  (5)  Emphasize preventive medicine.  This, too, is an element incorporated into the ACA, and deserves more attention.  It’s far better for all concerned to promote annual health check ups, healthy lifestyle and nutrition programs, and vaccinations than it is to cover the costs of heart attacks and preventable diseases.  The insurance corporation doesn’t have to pay out the claims for the heart attack, the hospital doesn’t risk providing uncompensated care, the physician doesn’t run that same risk, and the person who avoided the heart attack in the first place is working and continues being a productive member of society.

(6) The slippery slope message is already in the public domain.  “What the Democrats really want is ‘single payer.’” Yes, some do.  The Republican cognitive dissonance hits the surface when some conservatives decry socialized medicine while famously exhibiting their “Get Government Hands Off My Medicare” signs.  However, this argument is both accurate and speculative at the same time.  Some Democrats are, indeed, in favor of single payer. Some are more likely to support a public option where private corporations are reluctant to enter the private health insurance market.  Others would simply prefer to sustain the present health insurance exchange marketplace system under the current provisions of the ACA.  There’s no monolithic, lock step, Democratic position on this issue, which is both a political problem for massing support for a specific proposal, and a political opportunity to let local voters select the candidate who best represents their views.

Third, we need to recognize that “repeal and replace” was never a serious proposal in the first place.  Had it been serious, then surely in the seven years since the passage of the ACA the Republican party would have come up with something more substantial than cutting Medicaid, limiting jury awards for malpractice, defunding Planned Parenthood, and giving tax breaks to the ultra-wealthy among us.  They were perfectly happy to vote in favor of complete repeal of the ACA until the burden shifted to their own backs, then the GOP controlled Senate couldn’t come up with 50 votes for a sham bit of legislation no-one wanted.

Slogans are effective public relations, but they are woefully inadequate policy proposals.  No, the ACA isn’t “socialized medicine.”  If it were then the Heritage Foundation wouldn’t have provided the framework of the plan as a response to Hillary Clinton’s health care proposals back in the ’90s.’  Granted, the Heritage Foundation didn’t include increasing Medicaid coverage, and it did include ‘tort reform,’ but the other similarities are striking even if hard-line Republicans in 1993 opposed the bill based on the framework, and it never came to a floor vote.

The GOP Zombie Bills may be gone, but the fight isn’t over.  And the obese ladies who would do better to follow the advice given by their doctors (covered as part of the ACA mandated insurance) aren’t yet singing.

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Filed under Health Care, health insurance, Medicaid, Nevada politics, Politics

The Moderate Heller Myth: Health Insurance Edition

Senator Dean Heller (R-NV) has cultivated his “moderate” image to the point that this adjective is attached to him with remarkable consistency — when if a person does even a perfunctory piece of research on his actual voting record what emerges is the model of a hard line conservative.  There is a pattern.  The Senator expresses “concerns” with a bill; then announces with ranging degrees of fanfare his opposition to a bill “in its current form,” then when the rubber grinds on the road surface the Senator votes along with the Republican leadership.

Why would anyone seriously believe he would support fixing the Affordable Care Act’s problems and not ultimately support what is now being called the “skinny repeal” version in the Senate based on the following voting record:

In 2007 then Representative Heller voted against the Medicare Prescription Drug Price Negotiation Act (HR 4).  Then on August 1, 2007 he voted against HR 3162, the State Children’s Health Insurance Program reauthorization.  The next day he voted against HR 734, the Prescription Drug Imports bill.  On March 5, 2008 he voted against HR 1424, the Mental Health Coverage bill.  Further into 2008 he voted “no” on HR 5501, the bill to fund programs fighting AIDS, Malaria, and Tuberculosis, and “no” again on the concurrence version of the bill in July.   If he had a ‘flash’ of moderation during this period it happened in the summer of 2008 when he voted in favor of HR 5613 (Medicaid extensions and changes), HR 6631 (Medicare), the latter including a vote to override the President’s veto.  By November 2009 he was back in full Conservative mode.

He voted against HR 3962 (Health Care and Insurance Law amendments) on November 8, 2009, and HR 3961 (Revising Medicare Physician Fee Schedules and re-establishing PAYGO) on November 19, 2009.

In March 2010 Heller voted against HR 4872 (Health Care Reconciliation Act), and HR 3590 (Patient Protection and Affordable Care Act).  He also voted against the concurrence bills.

January 19, 2011 he voted in favor of the Repealing the Health Care bill (HR 2).  He also signaled his stance on Planned Parenthood when he voted in favor of H.Amdt. 95 (Prohibiting the use of Federal funds for Planned Parenthood) on February 18, 2011.    He was in favor of repealing the individual mandate (HR 4), of repealing the Prevention and Public Health Fund (HR 1217).  May 4, 2011 he voted to repeal funding of the construction of school based health centers (HR 1214).

There was another “soft” period in some of his initial Senate votes in 2011, especially concerning the importation of medication from Canada (interesting since many prescription drugs are manufactured in other overseas sites).  See S. Amdt 769, S. Amdt 2111, and S. Amdt 2107 in May 2012.  On March 31, 2014 he voted in favor of HR 4302 (Protecting Access to Medicare).

He was back riding the Republican rails in September 2015, supporting an amendment to defund Planned Parenthood, (S. Amdt 2669) which failed a cloture vote.   Then on December 3, 2015 he voted in favor of another ACA repeal bill (HR 3762).    If we’re looking for patterns in this record they aren’t too difficult to discern. (1) Senator Heller can be relied upon to vote in favor of any legislation which deprives Planned Parenthood of funding for health care services, (2) Senator Heller can be relied upon to vote in favor of repealing the Affordable Care Act, and (3) Senator Heller’s voting record, if it illustrates any ‘moderation’ at all, comes in the form of dealing with prescription drug prices, but even that is a mixed bag of votes.

Thus, when he makes comments like the following:

“Obamacare isn’t the answer, but doing nothing to try to solve the problems it has created isn’t the answer either,” the statement read. “That is why I will vote to move forward and give us a chance to address the unworkable aspects of the law that have left many Nevadans — particularly those living in rural areas — with dwindling or no choices.

“Whether it’s my ideas to protect Nevadans who depend on Medicaid or the Graham-Cassidy proposal that empowers states and repeals the individual and employer mandates, there are commonsense solutions that could improve our health care system and today’s vote gives us the opportunity to fight for them. If the final product isn’t improved for the state of Nevada, then I will not vote for it; if it is improved, I will support it.”

We should examine them with some caution.   If he is referring to rural Nevada voters as ‘victims’ of the Affordable Care Act he might want to note that before the ACA there was one insurer in the northern Nevada rural market and if there is only one now that’s really not much of a change, much less a “nightmare.”  Nor is he mentioning that the proposed cuts to Medicaid will have a profoundly negative effect on rural Nevada hospitals. [DB previous]

That Graham-Cassidy proposal isn’t exactly a winner either:

“The new plan released Thursday morning and written by Republican Sens. Lindsey Graham (S.C.) and Bill Cassidy (La.) would block grant about $500 billion of federal spending to the states over 10 years to either repeal, repair or keep their ObamaCare programs.”

We have no idea if the number is an accurate estimate of what would keep the health care systems of all 50 states afloat — no one seems to want to ‘score’ anything these days.  Additionally, Americans should be aware by now that when Republicans chant “Block Grant” they mean “dump it on the states, wash our hands, and walk away” while the states struggle to keep up with demands to meet needs and provide services, operating on budgets which cannot function on deficits.

Then, there’s that perfectly typical Hellerian comment: “If it is improved, I will support it,” leaving the issue entirely up to Senator Heller’s subjective assessment if “it” has improved his re-election chances enough to go along with it while not upsetting his very conservative base.  Meanwhile, the media persists in repeating the “Moderate Heller” mythology, and we haven’t even begun to speak of his actions to thwart and later repeal any common sense regulations on the financial sector.

 

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Filed under conservatism, Health Care, health insurance, Heller, Medicaid, Medicare, Nevada Test Site, Politics, public health, Republicans, Rural Nevada, SCHIP

Embattled Bill Entangled Senator

While the Russians are in, or not in, meetings which are, or aren’t important, and which do or don’t offer trade-craft dangles — there’s a Senate version of the health insurance bill as egregious as its predecessors.  The hold music of the morning on Senator Dean Heller’s DC office phone is a static infused version of The Battle Hymn of the Republic while a person waits for an opportunity for leave a message for the Senator urging opposition to the health care insurance bill.

There’s a reason no one likes this bill — it puts insurance corporations back into the bifurcated market  with high premiums for those older and lower premiums (with higher co-payment and deductible out of pocket expenses) for younger, or less affluent, customers.  It puts state budgets at extreme risk. It slashes Medicaid funding (in conjunction with the proposed budget), thus placing services for children and the elderly in peril.

Senator Heller is described as being wedged into a hard place — between the desires of the hard right (and perhaps the bounteous coffers of Sheldon Adelson) and the hopes of his constituents and the Governor who want reasonable access to affordable health care insurance.

“Heller, in other words, has backed himself into a corner. Either he honors the concerns he raised just a few weeks ago, or reverses course and completes a very public betrayal – the year before his re-election campaign.” [NBC]

It’s time to offer Senator Heller a way out of this box — encouraging his continued opposition to the health insurance bill — call 202-224-6244; or 702-388-6605; or 775-686-5770.

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Filed under Health Care, health insurance, Heller, Politics

Health, Wealth, and Senator Heller: Recommended Reading

Health care continues as a high priority item for Nevadans, and Greg Sargent’s article for the Washington Post points out how the “GOP Stunt Backfired…and why,” is highly recommended for pulling the tarpaulin off the GOP obfuscation concerning the Affordable Care Act.  The New York Times reports on the impact of the health insurance battle on other elements of the GOP agenda.  Ian Millhiser warns us that if we stop paying attention, the GOP wins.  Meanwhile,…

Senator Dean Heller continues to spout the party lines (the part under the tarp) while ostensibly opposing the repeal bill:

“Under the ACA, premiums have increased 7 times faster than wages, and federal regulations under the law’s employer mandate have cut workers’ hours, wages, or both.”

Nothing like tossing one’s apples and oranges together and expecting to get grape juice.  Some significant elements are missing from this pithy bit of prose.  First, premiums have increased, but not at an equal pace in all states. Secondly, the rate of premium increases have slowed during the implementation of the ACA.  Third, wages have been stagnant during the past decade, but that has little to do with the enactment of health care insurance reform — in fact, lower wage working Americans were included in the Medicaid expansion– the very program the GOP wants to slash in order to provide tax cuts to wealthy Americans.

Senator Heller believes that re-importation of prescription drugs and allowing insurance purchases across state lines are part of the solution.  Notice that he’s not in favor of so much competition as to allow Medicare to negotiate drug prices in the manner allowed to the Veterans Administration.  Also notice that he’s not mentioning that some states have rather more lax requirements for the sale of comprehensive health insurance than others.  The “across state lines,” or “portability argument” sounds good until we recall that states build in consumer protections into their regulatory frameworks.  If we could be guaranteed that portability would be a function of the most rigorous consumer protections there’s something to be discussed herein; if not, it’s simply a formula for a race to the bottom.

This is no time to remove our attention to the decimation of health insurance affordability —

Senator Heller can be reached in Las Vegas at 702-388-6605; Reno at 775-686-5770; and DC at 202-224-6244.

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Filed under Health Care, health insurance, Heller, nevada health, Nevada politics, Politics

It Ain’t Over Until The Fat Golfer Sings

Senator McConnell’s Secret Health Insurance Shop is still working, with the Lobbyists/Elves seeking a way to offer goodies acceptable to the wavering and the wanton.  Keep calling!  and if you’d like more information to substantiate your comments there are some excellent sources.

Kaiser Family Foundation:   Your one stop center for research and analysis on health insurance issues.  Definitely a “bookmark this” recommendation.  Today, KFF notes that before the implementation of the ACA individual insurance plans for health care did not cover delivery and maternity care  in 75% of the policies; 45% of the policies didn’t cover substance abuse treatment; and 38% failed to cover any mental health care services.

If terms like “risk adjustment,” “re-insurance,” and “risk corridors” seem like something written in Minoan Linear A, the KFF has an excellent summation of these technical terms in easily understood American English.

There are also some analytical pieces on the impact of Republican suggestions for health care insurance “reform” as they relate to rural health care in the following:

Human Rights Watch — Senate Health Care Bill A Swipe At Rural United States.

MSNBC/Scarborough – Rural Health Care Would Be Savaged By This Bill.

There’s a narrative going around that Democrats haven’t brought anything to the table, which depends on whether we’re taking the long or short term view.  In the short term this would be true — because the McConnell Secret Health Insurance Shop didn’t invite any Democratic participation,  for that matter there seems to have been some Republican Senators who were left in darkness.  The longer view would note some of the following:

Senator Franken’s “Rural Health Care Quality Improvement Act of 2016” (pdf) S. 3191 (114th Congress) was introduced in July 2016 and “died” in the Senate Finance Committee.  The bill would have amended two titles of the Social Security Act to improve health care in rural areas of the United States.

There is Representative Jan Shakowsky’s CHOICE Act, H.R. 635, which would establish a public option under the ACA.  See also S. 194, Senator Sheldon Whitehouse’s CHOICE Act.  There’s Rep. Gene Green’s HR 2628 to stabilize Medicaid and the Children’s Insurance program.  Rep. John Conyers introduced his form of “single payer” in his Medicare for All bill, HR 676.  On the topic of making pharmaceuticals more affordable:  Senator Sanders – Affordable and Safe Prescription Drug Importation Act S. 469.  Senator Klobuchar has a bill “… to allow for expedited approval of generic prescription drugs and temporary importation of prescription drugs in the case of noncompetitive drug markets and drug shortages.” S. 183. Rep. Kurt Schrader introduced H.R. 749 to increase competition in the pharmaceutical industry.  Senator Ron Wyden introduced S. 1347, RxCap Act of 2017.

Senator Klobuchar has also introduce a bill supporting Alzheimer’s caregivers in S.311.  Rep. Derek Kilmer’s bill, H.R. 1253, seeks to improve access to treatment for mental health and substance abuse issues.   This is by NO means an exhaustive list of what can be gleaned from Gov.Track, but it does illustrate that the Democrats are not without suggestions — negotiating drug prices for Medicare, stabilizing the current system, public options, single payer — it’s just that these bills won’t get out of Republican controlled committees and they didn’t make it into Senator McConnell’s Secret Shop.

Indulge in no victory dance, we’ve seen this movie before … don’t believe that some minor blandishment won’t be enough to lure Senator Heller from his current position …don’t think that the products of McConnell’s Secret Shop have stopped coming off their assembly line.

Senator Heller can be reached at 202-224-6224;  702-388-6605;  775-686-5770

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Filed under Health Care, health insurance, Medicaid, Medicare, nevada health, Pharmaceuticals, Politics, public health