Health related quality of life?
Health related quality of life?
In the graph there are:
– Different types of outcomes
– Individual and environmental characteristics play into most (non medical)
– patient’s preferences & psych/emotional factors play a strong role
– Going from left to right outcomes are less and less controlled by “medical care”

*Biological* (molecular/genetic factors, diagnoses, laboratory values, bodily function)
*Symptom* (whole organism; emotional/psychological, physical, subjective, stigma, *drives care seeking and costs*)
*Functional Status* (biology & functional ability doesn’t always coordinate; affected by dimensions: physical, social, role, emotional; complexity: motivation; FDA now measures; objective)
*Health Perceptions* (by definition subjective, integration of previous; predictor of mortality)
*Overall quality* (not directly correlatable with functional status i.e. paraplegics; strongly related to economy, religion, health of others)

Force field and well-being paradigms of health
Force field and well-being paradigms of health

Social gradients of health by race
Social gradients of health by race
– All/black/Hispanic/white: same income gradient in all
– Bridge case: how does the AA community in the US think about the mental health system? Why?
– Race effect: the wealthiest whites are still healthier than the healthiest blacks and hispanics; same with the poorest whites

Improvements since the application of preventive and clinical services?
– 30 years in improvement in life expectancy seen between 1900 and 1950
– 5-5½ years attributed to improvements in medical care
– 7 to 7½ years of increase between 1950 and 1995
About half attributed to improvements in medical care

Iatrogenic disease?
Disease and death caused by physicians and medical care; 2-4% all deaths
Loss of life expectancy 4-8 months
10% of health attributed to medical care

Determinants of health?
Social Circumstances
Medical care

*Social determinants>medical care in terms of which affects our health more*

9 Areas of disadvantage for the USA
1. Adverse birth outcomes
2. Injuries and homicides
3. Adolescent pregnancy and STIs
5. Drug related mortality
6. Obesity and diabetes
7. Heart disease
8. Chronic lung disease
9. Disability

What was the Sensipar story?
– Sensipar is a drug for osteoporosis and bone disease
– It is usually given via FFS; one can’t be given too high of a dose or else risk of stroke
– because of the risk, it was momentarily bundled with dialysis costs and couldn’t be charged extra
– It was excluded from bundling in 2010 and again in 2013
– inserted into fiscal cliff legislation (package of spending cuts), which increased medicare costs considerably

Market Justice vs Social Justice framework
Market Justice vs Social Justice framework
-economic good vs social resource
-free-market vs gov involvement
-market is efficient/equitable vs gov is efficient/equitable
-determined by demand vs determined by central planning
-based on ability to pay vs ability to pay not important
-economic reward vs basic right

-individual responsibility vs collective responsibility
-purchasing power vs basic package of benefits
-little obligation vs strong obligation to collective good
-individual well-being vs community well-being
-private vs public solutions
-ability to pay vs planned rationing

Markets don’t work well in health care because? (Krugman article)
– You can’t know (in general) *if or when you will need* care, and when you do it is very expensive
– Therefore you need *insurance*, but insurance companies make money by *NOT paying* for health care, so their interests may not be aligned with yours (*principal-agent problem*: disconnect b/t goals of company and patient; company is given the responsibility and authority to take actions that affect both the principal, but can also affect the agent)
– The gamesmanship of trying to cover people who won’t need care, and *denying claims* is expensive
– Health care is complicated, and you *can’t comparison shop* or rely on your experience
– Even doctors have conflicts of interest because they can get paid for “selling” you services that may not help, or may hurt, and that *you may not have the knowledge to refuse* (again, the principal-agent problem)

How has health care changed since 1950?
– US health care expenditures have risen rapidly
– Rise of third-party payment (insurance) instead of out-of-pocket payment
– Increased government role in funding health care
– Decline in inpatient care
– Shift in physician workforce: more females, specialists, hospital-based doctors
– New medical technologies

Markets would work if: (Mackey article)
– *Remove the legal obstacles* that slow the creation of high-deductible health insurance plans and health savings accounts (HSAs)
– *Equalize the tax laws* so that employer-provided health insurance and individually owned health insurance have the same tax benefits
– *Repeal all state laws* which prevent insurance companies from competing across state lines
– *Repeal government mandates* regarding what insurance companies must cover

History of insurance:
*19th century Europe*: origins of private insurance with guilds
*Early 1900s*: Blue Cross (Hospitals) & Blue Shield (Physicians)
Prepayment during Great Depression because of low occupancy rates and reduced ability to pay out-of-pocket for doctors
*Post-WWII*: employer-based private insurance (tax subsidies)
*1965*: Medicare and Medicaid pass
American Medical Association (AMA), a powerful interest group, opposes (argument was that it would overcrowd, erode quality, reduce physician incentives)
Generally, insurance is provider driven in the US (as opposed to Europe). –> needs of doctors

Blue cross Blue shield?
Blue cross:
– 21 days of hospital care for $6 per year
– *Prepayment idea* spread during Great Depression because of low occupancy rates
– Next: plans sponsored by *groups of hospitals*
– *American Hospital Association* (founded 1898) supported and the coordinated these groups

Blue shield:
– Great Depression reduced patients’ ability to pay MD fees out of pocket
– In 1939 the California Medical Association set up first Blue Shield plan *to cover MD expenses*
– Idea spread nationwide
– Controlled by *state medical societies*
– Starting in 1974 Blue Cross and Blue Shield plans began to merge

*BCBS is provider driven; unlike europe*

Why are interest groups so dangerous to health care?
– Policy making responds to financial resources of interest groups and re-election needs of politicians not to objective public and social needs
– Our system encourages self-interested groups of every conceivable type to play in the free market of ideas related to health care
– Deep historical distrust of government
– Reluctance to achieve more equal outcomes through redistributive public policy
– US political system makes it possible for special interests to have more impact

Moral hazard?
– when a party insulated from financial risk behaves differently than it would behave if it were fully exposed to the financial risk
– Overutilization if you have insurance
– Also more broadly, caring more about economic benefits versus health-based/moral ones

Goals of insurance
– Typically the goal of insurance is to protect against uncommon or rare, expensive events
– Because virtually all health care utilization, even a routine outpatient visit, is very expensive (especially in the US), health insurance generally covers most or all kinds of utilization
-can detect cancer early!
– PROBLEMS: *information asymmetry*–> providers know more than patients about costs whereas patients know more about their own issues than payers (*adverse selection* vs *cream skimming*)
Fight back on part of payers through medical underwriting and risk assessment and rate making (manual, community/pooled, or experience based)

Insurance facts:
*Actuarially fair premium* (total expected cost)
*risk premium* (cost above that that customers pay)
*loading fee* (costs over and above the actuarially fair premium cost; how to actually profit)
*Medical loss ratio:* percent of insurance income that goes towards health care
*Risk pooling*: Balancing risk across a pool of clients (large pool, more predictable)
*Asymmetric knowledge problem*: you know more about your health issues than the insurer
*adverse selection*: insurance buyers have higher health costs than non-buyers –> as a result, *medical underwriting* or assessing risk is used
*community rating*: a set premium for a whole pool (sick and healthy the same)
*manual rating*: sick people pay more; common in individual market
*experience rating*: dif employer groups pay dif rates
*cream skimming*: avoiding sick people

– Guards against extreme ED utilization (EMTALA)
– On balance, the healthy people’s premiums must cover costs of sickest people’s premiums

Oregon medicaid experiment?
– Compared people with Medicaid to those without Medicaid
-Increased use of health care services
-raised rates of diabetes detection and management
-lowered rates of depression
-reduced financial strain
-No significant improvements in measured physical health outcomes in the first 2 years

Why is cost sharing important?
[cost sharing = deductables, copays, coinsurance, etc]
– Attempt to *counterbalance* the natural tendency to *unnecessary utilization* by requiring payment at the point of service (moral hazard)
– Motivate patients to be smart shoppers or to have “skin in the game”

Problems with cost sharing?
– different information asymmetry problem (providers know more than patients)
– Medicaid co-pay example
– Poor decisions (i.e., decisions that are not in the self-interest of the medical shopper) are probably common
– Patients may lose incentive to take certain meds

Private insurance is costly: why?
– Private health insurance sector in the United States is fragmented and sets the benchmark for all health care prices in the United States (Medicaid and Medicare have to follow these prices or else their patients would lose access)
– *No price transparency*
– Patients should have more skin in the game, but implementing this has been hard –> Electronic information technology is making this easier (allow patients to bargain over fees; info on quality and prices)
Reference pricing: a blunt form of cost sharing

What was the RAND Health Insurance Experiment?
It concluded that by giving people health insurance with cost-sharing involved (copays, deductibles, etc), there was a 25% decrease in hospital visits and hospital use

–> did not result in worse health outcomes

Cost sharing balancing act?
– it works to reduce utilization
– it does nothing to insure that patients make the right decisions about what utilization to forego
– Current trend: increase patient cost sharing
– *Value Based Insurance Design (VBID)*: Reduce or eliminate co-pays for critical medications or other services to increase incentive
–> Evidence mixed on effectiveness

Rosenthal article (about the basal cell carcinoma patient)
– Dermatology: Big market $$$
– A seemingly minor medical problem can rack up big bills if it involves specialty doctors and if it is done in the grounds of a hospital
– *Specialists* engage in *aggressive lobbying*, and they seek to increase their revenues by doing new, *lucrative procedures*
– Doctors in US make more than those in other developed countries
– Their *salaries* account for *20% of healthcare expenses*
– Specialists earn an average of two and often four times as much as primary care physicians in the United States
– Due to salary differentials, about 25 percent of new physicians end up in primary care, and we are in primary care shortage (PCPs make up only 12 percent of physicians in practice)

What did the Soumerai studies in the 80s reveal?
People stopped taking certain medications because of a change in the Medicaid payment strategy (increased cost sharing)

Where do people under 65 get insurance (%s)
Where do people under 65 get insurance (%s)
Employer, dependent – 30%
Employer, own – 32%
Individual policies – 5%
Medicaid/other public – 15%
uninsured/ihs – 18%

2/3 of nonelderly have private coverage, 15% medicaid, 18 (*now 13)% uninsured*

*USA has primarily private health insurance, unlike any other country*

Types of private insurance
*Size based (ESI* or group or individual)
–> employee based has more risk pooling, less adverse selection, less underwriting since group-based
–> huge public subsidies since both tax exempt

*State licensed or “fully insured”* (i.e. BCBS)
–> 45% of the private insurance market
–> Regulated by states

–>Company insures itself rather than purchasing insurance
–>NOT regulated by states; regulated by federal government under a law called ERISA
*ERISA*- Employee Retirement Income Security Act

Changes brought by the ACA
*Guaranteed issue*: require insurers to accept all applicants in individual and group markets, regardless of health status, occupation, or other risk factors

*Guaranteed renewability*:
-Renewable at the policyholder’s discretion
-Exceptions nonpayment or late payment of premiums, for an act of fraud by the policyholder, or for other limited reasons

*Modified community rating*:
-Adjustments allowed for family coverage, geography, age, and tobacco use
-No adjustments permitted for pre-existing conditions, occupation, gender [think pregnancy], duration of coverage, credit worthiness
3:1 ratio of highest to lowest premium in 21-64 age group allowed

*Single risk pool*: claims experiences of all enrollees in individual plans pooled; reduces risk that sicker people will pay higher premiums

*Required Coverage of “Essential Health Benefits”*

*Medical Loss Ratio*: requirement that 80% of premium dollars in individual market be spend on care and quality improvement

What are the Essential health benefits? (as specified by the ACA)
Ambulatory patient services
Emergency services
Maternity and newborn care
Mental health and substance use disorder services including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including vision and dental care

Facts/trends about EBI
– It’s getting more and more expensive; earnings aren’t keeping up with premiums; eroding purchasing power and wages
-Tax Subsidies for ESI – Health care premiums are not counted as taxable income
– “*Tax expenditure*” is the amount of tax dollars that the government does not get in revenue because of this
– Totals about $250B, which is about the same amount of money as we spend on the whole Medicare program
– It has a regressive effect (higher income people benefit more)

Provider reimbursement methods
Units of payment: continuum of aggregation
– Visit or procedure *(FFS)* [incentive is volume>quality] [payer has financial risk]
– Per diem rates for hospitals
– *Episode of illness* [Global surgical fees, DRGs (Diagnosis Related Groups) for hospitals, Bundling]
– *Capitation payment*: a single payment per month or year for all care for a single person [provider has financial risk]

What was the case study on IMRT? (Intensity-Modulated Radiation Therapy for prostate cancer)
– Urologists have incentive to perform expensive surgery since it was based on FFS payment

What is managed care?
“An organized approach to delivering a comprehensive array of health care services through efficient management of services needed by the members and negotiation of prices or payment arrangement with providers”
– Set of tools that can be used to control costs
Cost = units * cost/unit
– Framework to think about tools
Reduce units, meaning reduce utilization
Reduce costs per unit or prices
Limit use of expensive and unproven technologies
*providers find managed care intrusive*

Managed care organizations (MCO)
Managed care organizations (MCO)
*IPA*: [middle man]
-IPA is a separate organization from the Insurer (Health Plan)
-IPA creates a provider network by contracting with solo, and group practices
-Physicians contract with IPA, not the HMO
-IPA takes capitation dollars from the HMO, and creates a variety of risk sharing relationships with providers

– Insurer negotiates a discounted FFS rate with “preferred providers”
– Enrollees can see preferred providers (for a lower co pay) or non-preferred providers (for a higher co pay)
– guaranteed influx of patients; more choice for patient

*HMO* [least freedom] [~ indicates all MCOs]
-pre-paid plans
– PCP following the “gatekeeper” model
~ holding providers accountable to standards of quality
– establishing an in network with which the enrollee must comply
– Among HMOs are staff models (own salaried physicians), group models (group practice contracted at once), network models (contracts with more than one group practice; often only with primary care practices)

– Variation of the theme of an IPA
– You can go “out of network” for care, but the copays are higher
– “open ended HMOs”

*HDHP* [high deductable health plan]
All costs up to the amount of the deductable paid out of pocket; Once deductable amount reached, the insurance kicks in (though there can be copays and coinsurances); Once the out-of-pocket maximum is reached, the enrollee pays nothing; usually affiliated with Heath Savings Account

Medicare history
Medicare history
-Passed in 1965, part of Social Security Act
-Administered by Executive Brach –> Health and Human Services (DHHS) –> Center for Medicare and Medicaid Services (CMS)
– Makes up *56% of the DHHS budget*
– Controversial history, tried to pass something many times before (finally passed by *President Johnson*)
– Entitlement program: funded automatically not subject to congressional appropriation

Successes of medicare
-First and foremost, it has improved protection against financial hardship from medical bills (only 2% of the elderly lack health insurance)
-the use of services by the elderly immediately increased
-Between *1965 and 1984, life expectancy at the age of 65 years increased by 15%*.
-the program stopped providing reimbursement to racially segregated health care facilities, in compliance with the Civil Rights Act of 1964 (immediate desegregation of hospitals)

Medicare eligibility & characteristics
US citizens & permanent residents who:
– Over 65 AND paid Medicare payroll tax for >10 years
– Disabled for 2+ years: Social Security Disability Income
– Have certain medical conditions: end-stage renal disease & ALS: Lou Gehrig’s disease
– 54 million enrollees; 17% of US population
– 65% have 3+ chronic conditions
– Half have income below $23,000 & have savings below $61,000 (135 FPL)

Dual eligibility!
Have Medicare AND Medicaid
Medicaid pays premiums, deductibles & copays, Medicare functions normally
9 million people

Medicare Part A
-Hospital Insurance Program covers *inpatient hospital services, skilled nursing facility, home health and hospice care*
-*Benefit Period*: begins when admitted and ends 60 days after discharged
Doesn’t cover custodial care (nursing homes) unless dual eligible

*Paid via*:
– Payroll tax: half from employee, half from employer
-Money goes into Hospital Insurance Trust Fund
-ACA increased tax for higher income individuals: Progressive Taxation
*Controlled via*
– Prospective Payment System (PPS) based on Diagnosis Related Groups (DRGs)

Medicare Part B
Supplementary Medical Insurance Program covers *physician, outpatient, home health and preventive services*, *emergency room* & ambulance, *rehab*ilitation, *mental health*, *dialysis*, *medical equipment*


*Paid via*:
-Financed by beneficiary premiums and general revenue
-Wealthy pay higher monthly premiums (progressive)
*Controlled via*
– Fee schedule (A fee schedule is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers. This comprehensive listing of fee maximums is used to reimburse a physician and/or other providers on a fee-for-service basis); RBRVS

Medicare Part C
– *Medicare Advantage* program allows enrollment in private insurance plans
– plans would fundamentally be the same as medicare but with more flexibility/extra services
– participants pay a monthly premium
– plans are similar to many managed care structures
-Enrollment in private plans started in 1970s
-*Balanced Budget Act (BBA) of 1997* created Medicare+Choice (PPOs/Private FFS plans/High deductible plans with Medical Savings Accounts)
–> plans began to withdraw and reduce services –> enrollment dropped –> BBA reduced costs at cost of decreased access

Good plan choice
Out of Pocket Costs are lower and there are limits

ACA has targeted for cost cutting
Reduction in payments to plans phased in
Enrollment expected to fall

Medicare Part D
-Voluntary prescription drug benefit through private plans contracting with Medicare. (10% of beneficiaries have no drug coverage)
– Stand-alone prescription drug plans (PDPs)
– Medicare Advantage prescription drug plans

How it works:
Have to have Parts A and B to join
Must live in the plan’s service area
Once a year chance to join or change
Pay a monthly premium that varies according to what the benefits are
Income-related surcharges (earn more, pay more)

– Penalties for non-enrollment: 1% of premium x # months without coverage added to premium
-Dual eligibles get coverage through Medicare (not Medicaid as prior to 2006), and are automatically enrolled
-Subsidies for low income beneficiaries

*Donut hole*: required covered beneficiaries to pay for drugs out of their own pockets after they reached a certain spending level and before a catastrophic
–>Coverage gap (donut hole) will gradually be closed, starting in 2010 via ACA
–>By 2020 the coinsurance rate in the coverage gap will be reduced to 25%

*how its funded*:
Financed through general revenue (75%), payments from states (12%), and premiums (13%)

Milestones in Medicare:
*1983: Prospective payment system (PPS)*
based on Diagnosis Related Groups (DRGs)
–>Hospitals paid and adjusted, average payments per inpatient stay, according to diagnosis

*1989*: Congress reformed the system of physician payment, replacing reimbursement of reasonable and customary charges with a physician fee schedule derived from a resource-based relative-value scale *(RBRVS)*, which was designed to reflect the resources required to perform each of thousands of individual services.

Prospective payment for home health care mandated by *Balanced Budget Act (1997)*

*Medicare Modernization Act of 2003 (MMA)*. This new drug coverage (under a new Medicare Part D) → The MMA made a prescription-drug benefit available, on a voluntary basis, only from private plans, with a premium paid directly to the plan; also increased reimbursement to plans and created regional PPOs (so that beneficiaries in rural areas could benefit), and special needs plans

2003: the Congress increased payments to private plans and further expanded the types of plans that are eligible to serve Medicare beneficiaries. Payments to these plans under what is now called *Medicare Advantage* were set higher than the costs of covering the same beneficiaries under traditional Medicare

ACA effects on Medicare
– Focus on prevention (free wellness visits, screenings, vaccinations)
– Focus on primary care: 10% bonus payment for primary care services 2011-2015
– Center for Medicare & Medicaid Innovation to test reforms & new models- $10 billion!
– Cost reduction 716 billion over 10 years… seems to be working

– Medigap is private insurance
– Largely because of a variety of problems/scandals in Medigap over time it is become highly regulated
– Covers out of pocket payments for Medicare services
– Over 9M beneficiaries have Medigap policies
– There standardized types of Medigap that can be sold by private insurers

Problems with healthcare system (Koller)
1. U.S. spends a lot on healthcare, but we don’t necessarily reap all the benefits
2. ACA tries to help improve the quality of U.S. healthcare through:
-Increasing access to insurance
-Reducing Medicare costs
3. We spend more on healthcare than other social services
4. Specialty care is over-emphasized, and primary care is under-valued
5. Multiple-payer system is confusing for patients and providers.

Solutions to make primary care more important
1. Online insurance market to guide buyers
Will buyers be individuals? Organizations?
2. Incrementalism
Focus on getting more money for better quality primary care, and getting alignment across payers
Use public levers to create that alignment
Build stakeholder support for changes.

Medicaid history
– Enacted in 1965 by Social Security Amendments adding Title XIX.
– Jointly funded by federal and state governments
– Federally defined core benefits and populations
– States define optional groups and benefits to cover
– Originally, entitlement program for low-income families receiving cash assistance
– Coverage now expanded to certain groups that meet certain criteria.

Medicaid eligibility
– Approx. 68 million people covered
– *1997: coverage expanded to children through SCHIP*
Uninsured children <200% FPL who do not qualify for Medicaid - 2014: Under ACA, childless adults (19-65 years old) under 133% FPL have option to be covered Covered: - Low income pregnant women, children, and parents - Children with Special Health Care Needs - Low Income Adults with Disabilities - Low Income Elderly - Low Income Childless Adults in States Opting for Medicaid Expansion *Vary by state*

Medicaid big picture
75% of Medicaid patients are in private managed care plans
100% of people who buy insurance on the health insurance exchanges created by the ACA will buy private insurance (who do not qualify for Medicaid)

People not covered by Medicaid
NOT covered:
Low Income Adults- optional
Low Income Childless Adults- optional
Low Income working adults make up majority of uninsured

Eligible, but not enrolled

5 year wait for legal immigrants
No coverage for undocumented or temporary residence

How is medicaid financed?
22% of state budgets (biggest single category of state expenses)

Money comes from:
Income Taxes
General Sales Taxes

– Intergovernmental Revenue
– Federal transfers to states
– Determined annually based on per capita income
– “Matching” percentage (Cost to state and cost to federal government; State responsible for defined percentage of Medicaid costs; FMAP ranges from 50% to 76%)

Example of how FMAP works…
Rhode Island FY2012 FMAP 52%
For every dollar spent, RI is reimbursed 52 cents by the federal government.
In FY 2010, FMAP was 63% indicating a 63 cent federal reimbursement for every state dollar spent.

Charges & Miscellaneous Revenue

Medicaid cost sharing
– Children, Pregnant Women, and other vulnerable groups exempt from any cost sharing

– States have option to charge premiums and to establish OOP requirements
– Maximum OOP limited
– Individuals who fall in higher income spectrum of Medicaid eligibility more likely to have cost sharing
– Cost Effective measures taken by States
– Example: Use of generic drugs
RI Example of RIte Share and terminating eligibility for some groups
-Total cost sharing cannot exceed 5% annual family income

Medicaid benefit
– Federally required to cover certain mandatory benefits (physician services, pediatric & family services, hospital services, nurse midwife services, lab & xray, transportation services, tobacco cessation, family planning, nursing facility services)

– Established and administered by each state
Determines type, amount, duration, and scope of services

– States also permitted to cover other services designated as “optional”
Many “optional” considered essential i.e. prescription drugs

Medicaid waivers
Way of increasing flexibility in Medicaid services and eligibility

Must be budget neutral!

– Different types of waivers: research and development, demonstration, managed care, and HCBS
– This requires states to be creative in the demonstration projects created. Most demos are implemented as a way to test a new way of saving money…..such as paying for Home and Community Based Services for those who might otherwise be placed in a nursing home, but really shouldn’t be there.

Disporportionate share hospitals?
Provides financial relief for hospitals that serve the poor
“Safety Net” Hospitals

Federal payments for hospital with high Medicaid/low-income patient volume
$11.3 billion distributed in 2011 from Federal –> State
DSH payments differ per uninsured person in each state

State decides threshold of Medicaid/low-income patient level and services provided to receive DSH funds

Medicare is a federal government program that pays for the health care costs of US citizens that are above the age of 65 years and the disabled. The federal government enters into a contractual agreement with private insurance companies that …

The U.S. health care system is the subject of much polarizing debate. At one extreme are those who argue that Americans have the “best health care system in the world”, pointing to the freely available medical technology and state-of-the-art facilities …

In general, Part D provides insurance coverage for beneficiaries’ prescription drugs. Those who are enrolled in the program (either voluntarily through private insurance companies, or if they do not select a program, CMS will enroll them in a PDP, as …

Abstract This research paper will explain the payment expectations of government, commercial, and liability insurances, as well as self-pay/cash pay patients. An in depth explanation of how they differ, such as rules, will be made. This report will help readers …

Abstract This research paper will explain the payment expectations of government, commercial, and liability insurances, as well as self-pay/cash pay patients. An in depth explanation of how they differ, such as rules, will be made. This report will help readers …

The second part is a voluntary insurance program for persons age sixty-five and older. Monthly premiums were $46. 10 in 1995, and general tax revenues finance expenses not covered by premiums (about 75 percent as present). The cost of the …

David from Healtheappointments:

Hi there, would you like to get such a paper? How about receiving a customized one? Check it out