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Jess Fiedorowicz's picture

[Dr. F. has returned! --lambert]

I'm currently online and would like to thank Lambert for contacting me to set up this live blog. I'm looking forward to talking to everyone about single payer.

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chicago dyke's picture
Submitted by chicago dyke on

thank you for coming on the blog. and please, although people here are very, very serious about health care reform, sometimes we can be a little...salty and irreverent. it's a hallmark of the blogosphere, as i'm sure you've noticed.

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

Thanks. I'm serious about health care reform as well and am looking forward to any discussion.

Submitted by lambert on

Iowa obviously has a very strong organization.

Up here in Maine, not so much, although with an aging and poor population, there's such a great need for it. However, there's a strongly independent "anti-government" view in a very large part of the populace -- not so much ideological as curmudgeonly.

How would you address these cultural issues?

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

Lambert,

I've certainly ran into similar sentiments here as well. I explicitly try to direct the debate away from such general sentiments and toward actual evidence.

My two key arguments for single payer involve social justice and fiscal responsibility. Most people can identify with at least one of these two areas.

It is clear that our system does not and will not cover everyone. That is an injustice. Our current system further discriminates based on a variety of sociodemographic and clinical variables. That is an injustice.

The differences in overhead between the private-insurance industry and government run programs is impressive. The difference between what we spend relative to other countries and what we get in return compared to other countries is similarly impressive.

Getting people to talk about data instead of resorting to name-calling is an important first step.

Submitted by lambert on

"Evidence-based politics," heh.

I take it you make a fiscal argument, not a "lives saved" argument. I've never understood why the latter isn't used more often, but perhaps the data does not support it?

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

Lambert,

Your current Gandhi quote is quite fitting.

"First they ignore you, then they ridicule you, then they fight you, then you win." -- Mahatma Gandhi

Right now, political opponents of single payer appear to recognize they cannot successfully debate single payer with any evidence-based discussion. They are then left with either excluding us from the debate or name calling. We need to get them to fight us. As Lisa Nilles, M.D. suggested at the Iowa forum. Obama promised to develop policy based on science. We need to hold the administration to this promise and engage them in an evidence-based discussion.

Andre's picture
Submitted by Andre on

thank you for your time. Now we saw how you were 'dismissed' the other day in your attempt to put it on the table, how can we get it put on the table permanently and give it due deference?

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

For those who want a little background, I first became involved in the single payer movement from frustration in trying to advocate for my patients who were struggling to access needed care in a fragmented and inefficient health care system.

Currently, I am a psychiatrist and clinician investigator at the University of Iowa. My research focus relates to the excess mortality associated with mental illness. With those with mental illness overrepresented among the uninsured and underinsured, I see access as one contributor to this problem.

Until recently, my advocacy efforts have been mostly local. This is a critical time for us to advocate for single payer as a socially just and fiscally responsible alternative to our current system. I thank you for the opportunity to take this effort to your blog.

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

Andre,

Despite evidence that the majority of Americans (and physicians) support single payer (that is when it is even included in the polls), I think there will have to be a public outcry to put single payer on the table.

It appears that lawmakers are interested in pushing a public-private hybrid, that will neither cover all nor address excess costs with overhead. I've heard lines frequently about how we need a "uniquely American solution" and how Americans don't want to give up their doctor or their insurance.

Clearly, politicians are trying to tell us what we want, instead of listening, to distract us from the polls and actual public opinion.

Yes, we want to chose our doctor. The reality is that single payer allows this better than our current system. Private insurance with its changing of networks, etc. makes this very difficult.

We need to remind politicians that we want everyone covered and that Americans and physicians support single payer.

There are also several "uniquely American" solutions. One is democracy -- the majority want single payer. Another is Medicare, which has worked for almost 45 years and provides health care to many disabled and senior citizens. With 3% instead of 31% overhead.

Submitted by lambert on

Why does single payer make that easier? Could you step through a concrete scenario/example?

Submitted by lambert on

Why does single payer make that easier? Could you step through a concrete scenario/example?

UPDATE And IIRC, the "uniquely American" thing is the Herndon Alliance at work. Do you have any counter to the talking point? It's one of those phrases that fits into a tiny little space in a tiny little brain, but if you've heard it a lot, it seems to be doing some damage.

Mandos's picture
Submitted by Mandos on

My family in Ottawa has one particular family doctor. When my brother moved to another part of Ontario, he got another doctor. If he wants, he can have that doctor fax over records to his original doctor in Ottawa and get treated there. And vice versa.

When I moved to the USA, I was given a choice of networks by my employer. I picked the one with an office closest to me, geographically, because I don't have a car and would like to walk to it. But if I move anywhere, then I won't be able to choose the closest doctor's office to me on that network, and I can only change networks at certain times of the year.

The only issue in Canada is that there has been, from time to time, shortages of primary care physicians in certain places due to the politics of medical education. But there are still walk-in clinics in many places that take up the slack---not optimal but acceptable.

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

We struggle with shortages here as well. Here in Iowa, it can take patients several months (3-6 months is not uncommon) to get an appointment with a psychiatrist. I referred someone to our headache clinic for severe migraines and they couldn't get an appointment for more than a year. We unsuccessfully tried to get an earlier appointment and I had a not so friendly reminder this didn't work after getting a consult note 14 months after the initial referral. This patient had insurance. The 48 million or so without insurance can't even get an appointment.

Nonetheless, these stories are anecdotes not data. The truth is that U.S. residents are more likely to have an unmet health need and more likely to struggle with access to care. As a clinician, this comes as no surprise to me.

Submitted by jawbone on

to give up every single doctor I was seeing.

I couldn't give up my allergist, as I'd spent so much effort finding someone who could help me, so decided to pay out of pocket for three years, when he finally got into the network. At that time I could afford that. Then downsizing and COBRA, then transfer to NJ individual plan with same insurer. I stayed with that insurer because of my doctors. And inertia. And difficulties, later, in trying to get answers I could trust about just what was covered from other insurers. Even with my own, I try to call at least twice to make sure the first answer is the same as the second. If different, I call again--then ask for supervisor.

Then, the GP I signed up with, who had been recommended by my previous wonderful, helpful, informative, respectful GP who was not available to use thru my insurance company, became disgusted with the paperwork overload from Aetna and left. So I had to find yet another GP. I tried to do some research, got recommendations, made calls. I cannot remember any doctor's office perons who was willing to answer the few questions I was using to try to establish a baseline. And, one of my base criteria was answered incorrectly by the GP I finally chose.

I could have, I suppose, just kept changing GP's, to actually have appointments with the doctors, but I tended to try to keep al low profile, I didn't want my insurer to have some reason to drop me, (I"ve since been told that as part of the individual insurance program in NJ, they can't drop someone. But, still....)

The cost for my insurance was becoming shockingly high (little did I know how high it can go!), and I decided to finally get the sinus surgery I'd hoped I could avoid and went to an ENT to set that up. I'd already been told I needed the surgery, but put it off reasoning that what can go wrong just might go wrong. But my face was swelling increasingly from the chronic infection.

That's when I was diagnosed with what was referred to as one of the "good" cancers by my ENT. He knew the insurance game well enough to know that I had no choice for my follow up specialist, as there was only one relatively nearby who was in my HMO. This specialist's office staff made my life a living hell for almost 6 weeks--My ENT wanted me to see the specialist before my surgeyr; I had to have an appointment with the specialist before I could get a referral from my GP; the specialist's office kept throwing away my records faxed to them from my ENT (with coverletter); the staff was singularly unhelpful and the person I was "assigned" to was new and added to the mess up; finally, my ENT's office person stayed on the phone while she faxed my paperwork and made the people actually read the cover letter.

That experience was horrendous--I was shaking while dialing the phone. I knew so little about my cancer, had so many questions, and no one to ask. Thank goodness for the internet and the information and then bulletin boards, informed chat groups, resources I found there. Kept me sane, really.

My wonderful allergist had made a recommendation for two other specialists, both of whom were not available to me.

Given the newness of the idea of having cancer, my multiple calls to an unrecpetive office staff made that timeframe hell. I can't imagine what a person who was not basically feeling basically well would do in such a situation.

BTW, it was better than what happened to a friend of a friend of mine. That person was in an HMO, was diagnosed with advanced cancer, but his HMO kept putting him off for weeks in getting a referral to the most expert docs for his type of cancer. He died of this cancer within months. Could he have survived with immediate care? I don't know. I do know that he was incapable of fighting the system, and my friend in NJ, who had worked for a Blue Cross/Blue Shield claims department up here about 15 years ago, was making calls to FL on his behalf and getting nothing but runaround. We decided the insurer saw his case was very difficult, at best, and was running out the clock.

I've looked for different specialists--the one's with great recommendations have been out of network. One that was in took two hours to drive to, didn't have hospital priviledges near to where I live, and I decided that was too difficult to deal with.

Now, notice how often there were multiple calls about the same thing, in just this cursory summary. When there are referrals, I have to make the appointment, call my GP's office, give info for referral. Then, the GP's office is supposed to fax the referral to the specialist. I try to remember to call the specialist's office to make sure the referral has been sent--and received and noted. Amazingly, especially with any new doctors, I more often than not have to call the GP's office to tell them the receiving office did not have the referral; then the calls can go on for awhile. Infuriating.

Oh, and I love the lab work and test facilities who don't know the rules and demand a referral when one is not required (they're supposed to take prescriptions). So I call the CP, tell them them the situation, and sometimes they can talk to lab person, sometimes they fax over an unneeded referral as the easiest way out. And I play that game bcz I don't want to be stuck with some ungodly expensive test bill in case something's changed somewhere in the bureaucracy....

OK, I'm exhausted thinking about this hellacious health blockade system devised by Big Insurance.

Submitted by jawbone on

altho that may happen.

On my cancer bulletine board, there are people trying to manage the ongoing repeated tests required to know if the cancer has been ablated, come back, spread. They stretch out appointments, they put off tests. They hope. And are scared. I cry thinking about them.

And for all here who are living "naked."

Health Blockade System.

Why can't Obama see that we can't afford to NOT HAVE single payer?

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

Jawbone,

I'm very sorry you had to go through all of that. It does well illustrate these problems in the system and why it is so ironic that opponents of single payer suggest you wouldn't be able to choose your doctor, when the opposite is, in fact, true.

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

Lambert,

I agree that the lives saved argument is most compelling. I'm driven to the cause for social justice reasons.

Not everyone finds the social justice element compelling (astonishingly) and the great thing about single payer is it is socially just AND fiscally responsible.

We spend more PUBLIC money on health care than the combined public AND private spending of all nations except Switzerland. I'm fine with that investment if we are getting something from it. We are not. We lag behind in health outcomes and have 48 million uninsured. That is not even close to acceptable. It is frankly infuriating.

And yes, people are dying. It is an injustice.

chicago dyke's picture
Submitted by chicago dyke on

makers. which means addressing them with a totally different language and area of focus. personally, even though i think many people are conditioned by propaganda to hate and fear any new "big government program," even one that would improve their health care situation, i'm not convinced that the number of people who think that way is relevant, or at least not as much as it used to be. i take heart in what Michael Moore reported about the making of his film "Sicko," in which he received an overwhelming number of responses to his requests for 'horror stories' about mistreatment from insurance companies. that film focused on the insured, and was all the more powerful as a result.

as in many areas, the will of the public is far more progressive than the attitudes dominant in Washington (we call it "The Village" here in the blogosphere). i believe that we need to put very hard, very specific pressure upon a number of key lawmakers, 'forcing' them to enact meaningful health care reform. i also believe that we should follow Dr. Dean's example, and bring health care to those states in which populist action is already common and can be more easily affected. i think we also have to fight 'bad' programs, in states like MA, while making regular contrast with those that are successful, such as can be found in a limited number of example in which states provide care to targeted groups, like children.

finally, i believe that health care professionals need to do a little house cleaning in their own organizations. /more later, gotta run/

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

Private insurance identifies certain physicians as in-network or out-of-network. This can change as contracts are renegotiated, if you change jobs, change insurance, or for that matter lose insurance coverage all together.

I have worked with many patients who have had to change doctors for insurance reasons.

With single payer, everyone is in and nobody is out. If you change jobs, you will remain covered and will be able to keep your physician. With a single payer system, you further don't have to worry about your doctor being in or out of network, because everyone will be in.

This also gets to some of the barriers imposed by our current system that single payer addresses, which I will get to (hopefully) in another post.

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

I second the comments of chicago dyke regarding the importance of putting pressure on lawmakers. In fact, that is perhaps the best way to make our voice heard. On some level, they need to know that the status quo or some incremental change in it is not acceptable. Lawmakers need to know that this issue matters and that the right stand may garner support while the wrong stand may cost votes. Further, it is simply the right thing to do.

Submitted by lambert on

I've got to step out and go to the State legislature and buttonhole reps on another issue, as it happens.

So, I want to thank Doctor Jess for dropping by and giving us these incredibly calm, patient, and lucid answers. (I"m sure his psychiatric training will be of great help to him in the blogosphere!)

chicago dyke's picture
Submitted by chicago dyke on

(sorry, had an inspector here for a minute)

i think that health care provider's unions and professional organizations can be strongly contrasted. several nurses unions, as we regularly report here, are progressive leaders on health care reform, and use their powers effectively, pressuring and educating politians and organizing public events, as well as aiding in the crafting of health care legislation. all that is terrific. compare this to some of the major physicians organizations, which have been incredibly regressive and active in opposing progressive reform. health care providers should remove those leaders of their organization who care more about hob-knobbing with politicians in the Village, or getting high-paying lobbying jobs after serving their terms. it may even be necessary for some health care professionals to form or re-form splinter organizations, the better to provide a separate lobby with a more correct focus than some of the national organizations. patients too should regularly encourage their providers to be politically active, as you are, Dr. Fiedorowicz. to the extent that patients can choose active and progressive providers, they should.

Susie from Philly's picture
Submitted by Susie from Philly on

Are that single-payers do not have a workable and specific political plan to make it happen - i.e. We can count on x number of votes.

The other objection is that the process of setting it up will take far too long, and that people need help right now. What are your thoughts?

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

The "uniquely American" phrase has indeed become another way of steering the debate away from issues of justice and evidence-based solutions.

I highlighted my two responses above. The first is that democracy is an American solution and the majority of Americans and majority of physicians support single payer.

The second is that Medicare is a uniquely American solution. It has payed the medical bills for senior citizens and the disabled for almost 45 years. It operates on only three percent overhead.

A single payer system has several advantages to Medicare given that everyone is in, everyone has a stake in making it better. Further, it reduces some of the system-wide overhead that cannot be reduced by simply adding another public system into the mix.

The current "public option" is problematic in that it doesn't reduce the overhead and even with regulation will not be on a level playing field. Therefore, it doesn't reduce costs and leads toward segregation of patients. If everyone is in, we all have a stake in making it the best system possible.

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

I agree that many physician organizations have not been progressive. I refuse to join the American Medical Association because of their lobbying efforts against single payer.

PNHP and the American College of Physicians are exceptions to this.

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

1) Workable Plan:

There is a workable plan. It's HR 676. Encourage your representative to support. Bernie Sanders has also introduced a bill in the Senate.

2) Implementation:

Medicare was successfully implemented in 9 months. We have better computer systems, etc. now.

I think that people need help right now is an argument not to wait for another incremental change to fail. We need single payer now. American businesses are bearing a huge burden with employer-based health care, when sadly we already spend enough government money to cover everyone had we a more efficient system. More Americans have found themselves among the unemployed and I'm sure the numbers of uninsured we quote will soon become antiquated.

We need to act now! We cannot afford to wait.

chicago dyke's picture
Submitted by chicago dyke on

and that is to stop believing what they are told in the mainstream media (we call it the So-Called Liberal Media, SCLM) and start talking to people who are actually active in health care reform. turning off the TV is a great start; too often it oversimplifies health care issues, in fiction and by omission of fact in reporting, and replaces fact with propaganda, often blatantly directed by insurance companies and those hateful enough to make political hay by extending human suffering.

providers and patients, and employees of health care concerns of all kinds, should make it a point to exchange facts with one another, and their neighbors and friends. information is power, and one way people can become more empowered to bring about the reform we all need is by arming themselves with facts. we try hard at this blog to provide that, and people should share sources of information with those who may not be familiar with some of the progressive work that is being done.

our politicians take their cues from lobbying groups, who often write the legislation for politicians, handing over pre-crafted bills that favor insurance companies and large corporations, which in turn go unread by the very politicians who vote on them. people can and should take that example and turn it on its head, slamming elected officials over the proverbial head with countering information, and demanding that they remember just who they actually work for- us. that's not going to happen so long as people blithely accept nonfactual tripe that passes for "reporting" on health care issues and legislation, on most outlets of the SCLM.

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

Yes, I think the media coverage is often disappointing in its breadth and depth, especially on television. Health care reform requires a thoughtful approach.

chicago dyke's picture
Submitted by chicago dyke on

i have to take my leave from this discussion, but i'd like to thank you and remind you that blogging is free of the restrictions of time (sort of): i'll be back later to review additions to the discussion and i hope others will as well. the comments made so far will remain, and generally people stop by at all hours and add more. also, if you could, Dr., would you mind stopping in again tonight, around 9pm? if that's not possible no worries, but we have advertised your post and discussion for that time, sorry if there was a mixup. again, thank you so much for your contributions here, and in this battle for real health care reform.

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

I can log on later this evening. Did you advertise for 9 p.m. Central or Eastern?

Jane Hamsher's picture
Submitted by Jane Hamsher on

Can you tell me if you or any other single payer advocate have been included in the weekly meetings Kennedy is having?

http://wonkroom.thinkprogress.org/2009/0...

Many of the parties, from big insurance companies to lobbyists for consumers, doctors, hospitals and pharmaceutical companies, are embracing the idea that comprehensive health care legislation should include a requirement that every American carry insurance.…

The 20 people who regularly attend the meetings on Capitol Hill include lobbyists for AARP, Aetna, the A.F.L.-C.I.O., the American Cancer Society, the American Medical Association, America’s Health Insurance Plans, the Business Roundtable, Easter Seals, the National Federation of Independent Business, the Pharmaceutical Research and Manufacturers of America, and the United States Chamber of Commerce… But so far Republican aides have stayed away from the sessions, saying they felt they would be relegated to a secondary role, with no opportunity to set the agenda or choose the outside participants.

I've been trying to get an answer to that question for a while, with no success.

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

Jane,

I don't know the answer to your question, but I will run it by the PNHP national office to see if they know. Hopefully, I can get back to you by this evening.

Mandos's picture
Submitted by Mandos on

I guess Dr. Fiedorowicz is probably off now, but...

I remember someone around here raising the problem of the adjustment of the number of people employed in health administration, which seems to be quite large and certainly too many for a single-payer system if the Canadian experience is representative. Do we have an assessment of the economic impact of quickly adjusting those jobs away?

On another note, the "uniquely American" phrase to me represents the claim that in the USA, private profits are of intrinsic moral value, and what does not result is private profits is not "American". A surprising number of people actually believe this!

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

E-mail from Mark Almberg from PNHP:

Hi, Dr. Fiedorowicz,

The answer to the question is no. No single-payer advocates have been invited to take part Kennedy's closed-door meetings.

While it's true that 500 unions, including 39 state federations of the AFL-CIO, have gone on record in support of H.R. 676, and that the national AFL-CIO executive council adopted a resolution in March 2007 endorsing the concept of Medicare for All , the AFL-CIO has not been an advocate for single payer. Instead, it has embraced the HCAN approach of a so-called private-public mix, which, as you know, we have described as unworkable.

So again, the answer is no.

Best regards, Mark

vastleft's picture
Submitted by vastleft on

Thanks so much for doing this, Dr. F.!

I love this statement you posted here:

Right now, political opponents of single payer appear to recognize they cannot successfully debate single payer with any evidence-based discussion. They are then left with either excluding us from the debate or name calling. We need to get them to fight us. As Lisa Nilles, M.D. suggested at the Iowa forum. Obama promised to develop policy based on science. We need to hold the administration to this promise and engage them in an evidence-based discussion.

Seems to me the best way to "get them to fight us" is to raise to scandal-pitch the manner in which single-payer has been deliberately excluded from these supposed "listening tours," including the Daschle house parties that were designed to keep single-payer discussions at bay.

What, besides your own comments being expurgated at the White House website (along with being glibly dismissed by Gov. Culver), are the most egregious examples you've seen of single-payer being denied fair consideration in this rush/stumble to a "Uniquely American" solution?

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

Mandos,

You raise a common concern regarding jobs lost for those currently working in the private health insurance industry. HR 676 includes a provision that those jobs which are eliminated "have first priority in retraining and job placement in the new system." This will account for many, but not all jobs. Those who lose their jobs "shall be eligible to receive two years of USNHC employment transition benefits" equivalent to prior salary but not to exceed $100,000. This mitigates the economic impact of "quickly adjusting those jobs away." There are further a number of healthcare professionals working in the health insurance industry that may return to actually delivering health care if interested.

The excess jobs in the private insurance system come at great cost to our economy. It has been estimated that provision of health benefits adds $1500 to the cost of an American-made automobile, to list but one example. These excess jobs have an insidious effect on the rest of the economy and impair the ability of other American businesses to compete globally. In short, these jobs may actually cost us jobs.

You also ask whether this has been studied. While there is a lot of evidence that single payer will reduce overhead, more efficiently deliver quality care, and truly cover all; the government can and should do more to study this solution. We should insist that the Congressional Budget Office formally study cost and feasibility to put single payer on the same table as the other proposals that do little to reduce overhead and will not cover every American.

Mandos's picture
Submitted by Mandos on

...I glad, but not surprised, that this issue has been considered and policy proposals made.

Jess Fiedorowicz's picture
Submitted by Jess Fiedorowicz on

Vastleft,

One of the more blatent examples of single payer being excluded from the debate occurred with the March 5th White House Health Care Summit, wherein single payer advocates were excluded.

After much protest, Oliver Fein, M.D. and Rep. John Conyers, Jr. were finally invited. With the majority of Americans in favor of single payer, it remained grossly underrepressented even after the protest concessions.

Here are Dr. Fein's comments on the event.

vastleft's picture
Submitted by vastleft on

Creating popular awareness of, and outrage about, the way single-payer is being methodically kept out from the conversation may be our best means of forcing the administration to do the right thing. People don't like the smell of dirty pool -- it's up to us to make sure they smell that smell....

Submitted by jawbone on

Or, can only Lambert do that? Senior fellows? Keep it at the top or have something noticeable on one of the columns? And, I do have the times correct, right?

I got here late this morning, saw Dr. F had been on, and thought I'd misread the previous blurb, figured I'd missed the entire Q&A. Relieved to find tonight's still on.

Anyway to make it more visible for drop by visitors (and all, actually)?

Also, how can we get word out to other lib blogs?

OOOOOPS! Just saw the ad, under the t-shirt ad. Well, that show's how carefully I look! But, maybe something sticky in way of reminder post, whch stays at the top until the session?

My thnx to anyone who can do so.

lizpolaris's picture
Submitted by lizpolaris on

One argument against the idea that single payer is better than private insurance was posed to me by a former nurse. She said that there was/is a lot of paperwork and bureaucracy required by Medicare and Medicaid. So she feels that shifting private insurance paperwork to the government will not necessarily be a net improvement or cost savings.

How would you respond to her on this question?

Mandos's picture
Submitted by Mandos on

Comparatively little billing paperwork happens in the Ontario medical system. It's mostly electronic and mostly involves listing of services rendered via codes entered into a database. There is some (rather annoying) residency-proof bureaucracy before the Ontario Health Insurance Program covers you.

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