The Depressing Future of American Health Care

If you want a preview of the future of American health care, just look to Canada.


In 1997, Jacques Chaouilli, MD, a family physician in Montreal, Quebec, decided he could no longer tolerate seeing his patients suffer—sometimes die—lingering on waiting lists for treatment and/or specialty care. He started a private emergency housecall service that got shut down by the government because of its prohibition of private health care. He then decided to challenge Canada's law prohibiting patients from seeking—and doctors from providing—private health care outside of the government run single-payer monopoly health care system.

Dr. Chaouill had difficulty finding any lawyers willing to take his case, so he eventually decided to represent himself. He embarked on his own independent study of law, and eventually, got accepted into the Montreal University School of Law. After getting into numerous debates with his professors over the interpretation of Canada's Charter of Rights and Freedom (analogous to the U.S. Bill of Rights), he left law school, and pursued his legal education independently.

Ultimately, after many years, his efforts bore fruit. A lower-level court had ruled that Dr. Chaouilli was correct in contending that the prohibition of private health care violated ones rights to "life, liberty, and security," as guaranteed by the Charter of Rights and Freedom, but that the development of a two-tiered medical system was unacceptable to the Canadian vision of "equality."

In 2005, the Supreme Court of Canada heard Dr. Chaouilli's appeal, and ruled that the Canadian single-payer system led to situations whereby patients suffer and die on government waiting lists, in violation of their rights guaranteed by both the Canadian and the Quebec Charters of Rights and Freedoms. The Supreme Court ruled as unconstitutional the prohibition of a parallel private medical system in addition to the government mandated single-payer system.

Dr. Chaouill's heroic eight-year effort, during which time he sacrificed priceless time with his family and with his patients, left him financially distressed, but morally vindicated.

The Court's decision has since led to the growth of numerous private clinics, throughout the provinces, where patients can obtain private medical care for cash, in a consumer-driven market, and avoid having to travel south of the border to get off the queue.

A May 2011 article in the Canadian Medical Association Journal (CMAJ) stated: "What once was privatization trickle may soon become a wave." Dr. Zoltan Nagy, President of the Canadian Independent Medical Clinics Association, estimated that in 2011 there were over 300 private clinics in Quebec alone, including clinics emphasizing executive health and cosmetic services. A spokesperson for the Quebec Department of Public Health Services said that the clinics are not only increasing in number, but also in size, becoming "mini-hospitals." He noted that one-day cataract, knee, and hip surgeries are increasingly being performed in private clinics.

The colleges of physicians and surgeons for British Columbia and Alberta publish lists of independent clinics providing surgeries outside of hospitals. As of 2011, they listed 66 clinics in British Columbia and 60 in Alberta, providing multiple types of surgeries and dozens of services. Their lists don't include the many private imaging and executive health centers in those provinces.

The former President of the Canadian Medical Association, Dr. Brian Day, owns the private Cambie Surgery Centre in Vancouver, BC. In an interview in the CMAJ article, he says the proliferation of private clinics is a function of the inability of the public system to meet demand.

In an interview in 2009 by the Los Angeles Times, Dr. Day said, in justifying the proliferation of private clinics, "What we have in Canada is access to a government, state-mandated wait list… You cannot force a citizen in a free and democratic society to simply wait for healthcare, and outlaw their ability to extricate themselves from a wait list."

The Canadian experience provides an opportunity to anticipate the future of health care delivery in the United States.

Over the past 20-30 years, the practice of medicine has been slowly morphing into a government-run enterprise, often with private health insurance companies acting as the intermediaries. Medicare price controls serve as templates for private insurance reimbursement arrangements. Managed care, encouraged and nurtured by federal legislation, requires providers to obtain authorization from faceless bureaucrats in order to provide many services they deem necessary for their patients. Guidelines and protocols, drawn up by committees and panels serving federal regulators, are imposed upon providers, requiring them to practice according to one-size-fits-all to models or face financial or even legal sanctions.

While not the simple Canadian style single-payer system, the U.S. system, especially with the advent of the Affordable Care Act, gets us to the same place—only in a more Byzantine fashion. True, there are multiple payers, but the insurance companies, as a result of the ACA, have become nothing more than publicly regulated utilities. The policies they will be allowed to offer patients are all designed and predetermined by the U.S. Department of Health and Human Services. The provider payment provisions, as well as the coding system, as has been the practice for years, will be pegged to Medicare reimbursement schedules.

Already we are seeing increasing numbers of doctors retire or slow down their practices in response to the changing practice environment. Many are selling their practices to hospitals and becoming shift-working hospital employees. Still others are dropping out of all insurance plans—even Medicare in some instances—and embarking on cash-only "concierge" medical practices.

In the meantime, demand for health care continues to rise, as 10,000 baby boomers become Medicare beneficiaries every day—and will continue to do so for the next 18 years. Emergency rooms continue to be overcrowded, as many people use them to obtain services that would otherwise be given by primary care providers, because they can't get in for appointments.

As perhaps another 32 million people are added to the Medicaid or private health insurance systems—the purported goal of the ACA—without a commensurate increase in the number of health care providers, one can expect wait times for physician appointments to only grow longer, and emergency rooms and urgent care centers to grow more crowded. The experience in Massachusetts after its health care reform of 2006 (upon which the ACA is largely modeled) tells us what to expect.

If Canada's experience serves as any guide, one can expect the one-tiered system in the U.S.—where anyone, regardless of socioeconomic status gets the same quality health care by the same physicians in the same hospitals with the same promptness—will slowly evolve into a two-tiered system, whereby those who can afford it will get state-of-the-art, prompt, courteous, consumer driven health care, while everyone else waits on line.

In fact, right before our eyes, it is already happening. The advent of "concierge" or "boutique" medicine was just a harbinger of things to come. In 2009, Dr. Keith Smith, anesthesiologist, managing partner and co-founder of Surgery Center of Oklahoma, took the radical step of posting online the list prices for 112 common surgical procedures. This includes the surgeons' and anesthesiologists' fees. They operate their clinic in a cost-effective, customer-oriented manner, and are able to provide their services for a small fraction of what a hospital would charge. They are attracting the business of increasing numbers of employers who provide health care coverage and are trying to rein in costs, as well as individuals with high-deductible insurance. Because of their competitive prices, they are attracting an increasing number of "cash pay" clientele.

In 1997, Vern Cherewatenko, MD of Tacoma, Washington founded SimpleCare, a patient and physician cash only provider network. According to a 2009 USNews.com article:

Medical practices that participate in SimpleCare's network agree to charge no-hassle, discounted prices to the organization's members. Patients pay a predetermined fee based on whether their visit is minimal length (five minutes), brief (10 minutes), short (15 minutes), medium length (20 minutes), long (30 minutes), or extended (60 minutes). Fees vary depending on the medical practice, but a good rule of thumb is $50 for a minimal visit to $300 for an extended visit. Cherewatenko says he isn't advocating that people go without insurance; indeed, SimpleCare accepts practices into the network that use the flat-fee structure for members but also take patients with insurance. But he does think it's a good idea to choose a high-deductible health plan and seek routine care through direct-pay providers who charge discounted rates.

The demographic cliff has been reached. With increasing numbers of Medicare and Medicaid beneficiaries stressing state and federal budgets—and future liabilities impossible to fund, provider reimbursements will continue to drop. Add to this the piling on of regulatory compliance costs, from electronic health records, to complex coding requirements, and we can expect to see more and more doctors unable to survive in private practice. The current trend of private practice consolidation and corporatization will only be matched by doctors closing their practices and becoming hospital employees. The old model of the private physician or small group practice giving personalized, one-to-one patient care will soon fade from memory.

Concurrent with the end of the physician as independent agent we see a shift in work incentives. Therefore, one can expect a decrease in physician productivity. Decreased physician productivity only exacerbates the physician shortage, which is, in turn, exacerbated by the sudden influx of Medicaid and privately insured patients. Wait times, a form of stealth rationing, will only get longer. It is worth remembering the adage: "Just because you have health care coverage doesn't mean you will receive health care." Ask any Canadian on a waiting list in the government-run system.

As the situation worsens, look for the growth of private, cash-only, clinics, specialty hospitals, and surgical centers across the nation—and perhaps some closely offshore. As part of the deal to get the American Hospital Association's endorsement, a feature of the Affordable Care Act denies Medicare certification to physician-owned hospitals other than those already in existence. However, physicians can still build and run their own hospitals if they are not interested in participating in the Medicare system. Therefore, look for groups of physicians to organize consumer-driven hospitals—not unlike Lasik or cosmetic surgery centers—that take no insurance and no Medicare. Finance companies already exist to help clients of cosmetic surgery centers finance their surgery, and it would be easy for these companies to expand into the growing niche of private direct-pay clinics and hospitals.

If the healthcare systems of the UK, the European continent, and now Canada provide any glimpse into America's future, look for a future where the affluent and the connected get state-of-the-art personalized, prompt health care, while the masses wait in line for delayed, impersonal, and often substandard care.

As PJ O'Rourke once said, "If you think health care is expensive now, just wait until it's free."

This article originally appeared in the Spring 2013 Issue of AZ Medicine.

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  1. If you were a cynical person, you might think that government health care is really just a plot by the rich to kick the middle class out of their hospitals and down with the poor where they belong.

    1. I recently had to see a specialist for some further testing. Three week wait! I felt like I was in Canada.

      1. It took me 6 weeks to get an MRI here (Canada). God damn pathetic.

        1. Start working at home with Google! It’s by-far the best job Ive had. Last Wednesday I got a brand new BMW since getting a check for $6474 this – 4 weeks past. I began this 8-months ago and immediately was bringin home at least $77 per hour. I work through this link, http://www.Mojo50.com

      2. That is nothing, my son has ADHD, we moved to Massachusetts a little over a year ago and our new PCP was unwilling to prescribe any medications to him to keep it in control unless he was being seen by a Psychologist.

        It took us over 10 months to find a child shrink who was accepting new patients

        1. Just think “they” modeled “Obama” kare after the Romney care here in Mass.

          The doctors and other professionals are bailing out of here, just wait till it gets even worse nationally.

  2. Eh, I missed one…I’m part of the 8%

  3. But, but, but, government already solved the healthcare crisis.

    Roderick Long read by Stefan Molyneux:


  4. but the insurance companies, as a result of the ACA, have become nothing more than publicly regulated utilities.

    Because like every cartel does, they gouged their customers. Of course state governments helped them by requiring more and more services.

    The ACA is bad but no one offered a better solution. A real free market solution would have begun by tearing down Medicare.

    1. Bullshit. I worked for an insurance company that exited the health insurance business. It had become a money loser.

      If an insurance company “priced-gouged” in a competitive market, they would simply lose business. The states and the feds have destroyed the industry.

    2. The ACA is bad but no one offered a better solution. A real free market solution would have begun by tearing down Medicare.

      Or at the very least converting it into a simple voucher program. Which actually has been suggested…

    3. Palin’s Buttplug| 5.6.13 @ 10:56AM |#
      “Because like every cartel does, they gouged their customers”

      Hey, shitstain, tell us how you made a killing owning the stocks of these ‘gouging’ companies.

    4. Cartels are created by the government. The ACA only strengthens their monopolistic practices. Just look at how the Interstate Commerce Commission eliminated “price gouging” in the railroad industry.

      Rothbard was right. “Progressives” are useful idiots…for the cartels.

    5. Know what I did when All-State forced me to part of the Boomerang racket? I changed insurance! At a better rate to boot! If there’s a monopoly, you can bet the government is behind it breathing life into it.

    6. Because like every cartel does, they gouged their customers.

      I used to be a health insurance underwriter. “Gouging” people who can cancel coverage and move it to another carrier isn’t nearly as effective an underwriting strategy as you apparently think it is.

      1. “Cartel” also doesn’t mean what you think it does.

    7. You mean with their sub 4% profit margins?

      That’s some real gouging there

    8. The ACA is bad but no one offered a better solution.

      There weren’t other comprehensive do-everything-for-everyone ‘solutions’, if that’s what you mean. There were offers to fix the low-hanging issues of tort reform, etc., but they always got shot down. Democrats figured they owned the issue and would not allow any contributions from Republicans. It wasn’t a priority for most Republicans.

    9. ACA is just s slow motion bail out for insurance companies. They can climb in bed with DC and get everything they need over time.

      The people will suffer and DC and Company will get rich

  5. “the one-tiered system in the U.S.?where anyone, regardless of socioeconomic status gets the same quality health care by the same physicians in the same hospitals with the same promptness”

    Unless your name is Matt Welch, in which case you get no fucking health care at all, because no one will fucking insure you, which makes you goddamn lucky that you married a French woman so that you can go to France, where, according to Matt, the health care is much, much better than it is here.

    1. Health care != health insurance.

  6. I’ve been living in Montreal for the past 21 months or so. I haven’t had to go to the doctor (outside of dentist and optometrist, which goes just like it did in the States), but my wife did use a clinic a few times when she got sick. It was OK…first come, first serve, which was a little annoying when trying to plan your day, but effective. I haven’t personally heard any horror stories about waiting lists from any of my Canadian colleagues, or in the news. I’d vastly prefer to have a market-based health system, but in my personal and second hand experience, the Canadian system has delivered adequate care.

    1. From what I have read, lack of services and waiting lists are prevalent in the more rural areas, and not so much in the urbanized areas. I read one article where one province was actually paying for people to go to India for surgery.

      1. It all changes when you need something major done. Waiting lists to see specialists are at least 6 months. Waiting lists for major non-life threatening problems requiring surgery can be years.

        And there is no way to walk in and say, listen, I will pay whatever you want, I want this work done this week. No matter what you get in line, and the line is long. People routinely go to the doctor for the common cold. The abuse of the system is incredible because its free.

        1. “People routinely go to the doctor for the common cold”

          an acquaintance who is an MD from Canada mentioned that you do this just to establish a place in line in case it is something other than a cold.
          If you do not, and it is something more serious, you start at the back of the line when that becomes obvious.
          IOWs, it positively encourages over-consumption.

        2. Exactly Smilin’ Joe – you don’t know until you need it and when you do….good luck.

          I’ve had three surgeries done in Canada. While I can’t complain about the quality of the surgeons (at the time they serviced the Montreal Canadiens and Expos)I do realize they were just ACL/shoulder surgeries.

          After a hockey injury where my shoulder popped I had to take an ambulance to a local hospital on the South Shore of Montreal. I waited 3 hours to pop it back in. They forced me, in pain, to take fucking x-rays when I knew all I needed was to move back into place. All that time wasted loosened my ligaments – it still bothers me. Just a personal annoying story.

    2. Lynchpin, I live in Montreal – all my life. We should talk. 21 months is not a lot of time. Allow me to tell you, adequate is not acceptable and try and not get very sick, ok? Because then you’ll see.

      Not only that, there’s a doctor/nurse/GP crisis in Quebec. Health in this province is in a state of corrupt anarchy.

      1. state of corrupt anarchy.

        That seems to be sort of a thing up here.

        1. No kidding. But do you notice we have no “problems” and that everything bad happens in the USA?

          1. In my personal line of work, politics doesn’t come up very often. The one issue that people do roll their eyes about is the sequester and budget cuts, particularly at NASA and NSF. But they can’t complain too much since the USA does the vast majority of the heavy lifting in my field. If USA science funding vanished tomorrow it would absolutely devastate the careers of lots of my Canadian colleagues.

            1. Lynch, truth is America does a lot of the heavy lifting in many areas – it never stops the anti-American rhetoric.

              Quebec has a love-hate thing going with America.

              Where in the city are you? It makes a difference.

              1. Absolutely right about doing the heavy lifting. They rightly criticize something like Iraq, but can’t wait for us to jump in to Libya, now Syria, and probably Iran, soon. The hypocrisy really damages any moral credibility they have.

                I’m in NDG, but I don’t really socialize too much outside of work circles.

                1. “They” above was meant to apply to other Western governments.

                  1. That in a nutshell is the rest of the world. Give us money NSA, BFF, ok?

                    NDG ain’t so bad. Went to private school there.

                    It’s a part of town where you still hear English in peace; being near Montreal-West, Hampstead and Westmount. Quebec nationalists hate those places. Which means it’s good in my book.

          2. What I have always found striking is the relative lack of symbolic patriotism. Now granted, it’s Quebec – not the best place to go to find rampant Canadian patriotism. But still, you very rarely see private businesses flying the Canadian flag, while in the US it seems like EVERY business displays the Stars and Stripes. And across the border in NY and VT you see lots of Canadian flags at private businesses. In fact, there might be more Canadian flags right across the border than there are on the drive up to Montreal. But you almost never see a US flag at a Canadian business.

            1. Ha, that’s true. There are more Canadian flags in VT and NY. They respect the consumer. Quebec couldn’t give a rat’s ass about respect, they just demand it. It’s all this separatist bull shit that has blunted Canadian patriotism. You’ll see flags, though, in the rest of the country. Hop over to Ontario and you’ll see.

              Quebec thinks by dissing Canada it makes them more unique.

              One thing you’ll notice Quebec wants a lot of goodies from Ottawa and is not too fond of paying for things. And then comes all the insane xenophobic laws like bill 14 – which I hope doesn’t affect you at your work place.

              1. Nope. I’m at McGill. My wife, on the other hand, couldn’t find work and is now back in the States.

            2. “you almost never see a US flag at a Canadian business.”

              That’s the inferiority-complex part of our mindset.

  7. It will be just like the UK. You can absolutely have your ‘free’ hip replacement. But it’s going to take us 18 months to get you into the OR.

    Tell ya what champ. In the meantime we’ll give you some free crutches, and a discount voucher for a wheelchair. Just put your feet up and watch the opening to the London Olympics on repeat for now.

  8. my roomate’s step-mother makes $74 hourly on the computer. She has been without a job for seven months but last month her payment was $19480 just working on the computer for a few hours. Here’s the site to read more… http://www.up444.com

    1. Ms. Bartz, at $74/hour that would be 66 hours a week for a monthly check of $19480. I am only willing to work 5 hours per week. I demand better pay. Im calling my congressman

  9. Nagy, Chaouilli and Day represent the Triumvirate of Evil to the left here in Canada. No matter how rational and reasonable their arguments are (and believe me, they’re valid) and no matter how much of it is common sense, they get chastised and shouted down in a country that’s decided public health is a “political value” not meant to be touched.

    It’s insane.

    I discovered those three during my time at findprivateclinics.ca; a website where a friend started when he noticed the rise of private clinics. We jumped on board to sell listings and even flirted with the idea of starting a medical tourism company. We were mentioned in a couple of magazines/publications. McLean’s called us but the rat-journalists- girl who interviewed us basically stole all our clinics and posted them in the article without attribution. At the time, we were the only players in the game so we knew it was taken from our site.

    Anyway, we had to talk to a lot of hospital administrators (including the groups attached in the article – we spoke to Mr. Nagy as well) and not many, if any, sang the praises of public health. We have one of the most rigid systems in the OECD. Chaouilli was a hero to us the more we learned. Michael Moore, by contrast, was just an asshole. Love Cuba, fatass? Then go get served there if it’s so good. Goofball.

  10. Cancer treatment centers here in the US are covered up with Canadians.

    I wonder why…..

  11. So we go north for cheap meds and they head south for care to avoid lines. Hilarious.

  12. “…one can expect the one-tiered system in the U.S.?where anyone, regardless of socioeconomic status gets the same quality health care by the same physicians in the same hospitals with the same promptness”

    Surely you jest.

  13. I’m in my thirties, permantly disabled, and likely to die prematurely (I’m told) due to injuries sustained in Sweden’s healthcare facade. I also now have PTSD. The “evil white man” with whom I’m wed has carried nearly the full financial weight of this nightmare (for which I’m thankful but also very sorry). I’ve been unemployed four years due to illness due to medical neglect. We went into debt to save what we could of my life through private doctors. Thousands more have gone to a lawyer to fight the system for recognition of *its* wrongdoing. It’s disgusting, inhumane, and most socialists don’t even have the decency to be outraged. In such systems, human life is absolutely disposable. My story is a dime a dozen. But don’t try to tell the U.S. Left. To them, Sweden is perfect, and I must be a liar. I’ve written to my representatives in the U.S. multiple times to share this experience and how it relates to U.S. patients with the same and similar conditions. Thus far, “my” representatives have all ignored me. Word to the wise regarding socialized medicine: Fight this like your life depends on it, because it very well may.

  14. nomoss, your story is not unique and it’s the side of the dark side the left refuses to speak of. They look at the “ideal’ of public health and not the practicality from the patient’s point of view. It’s cost-centric and not patient-centric. Many people have stories like yours. How many anecdotal stories makes evidence?

    There are people trying bring awareness but it’s hard when you get tagged a “neo-liberal” or that you “lack compassion” and that we shouldn’t be American and all that strawman crap.

    Good luck. It is a game of Russian Roulette it seems.

  15. Gosh, the sheer economic ignorance, from people who posture as educated economists, is painful. Matt Yglesias wrote an article at Slate discussing the problem of doctor scarcity that is addressed here. His solution? No kidding, no crossed fingers – his solution was to reduce the compensation for health-care professionals, thus enabling the government to afford to hire more of them.

    These people will believe anything they need to. Just pass a law with a bunch of new regulations, new benefits, new subsidies, and it will magically fix everything – scarcity, price increases, universiality – because, government.

    And if it costs too much, we can always just print money and give it to poor people so that they can afford it.

    1. Y-glesias really needs to educate himself….badly. They want to believe a triangle fits into a square so badly they just come up with shit.

      We tried that in Canada. We throw money at the system and scream “you fucking work!” and we cut back by firing doctors and nurses like they did in Quebec and we scream “you fucking work!” and we increase taxes screaming in a Chinese accent…”you fucking work now!”

      Yet, it doesn’t work all that well.

      But here’s the thing Canadians will always argue; no one gets bankrupted in Canada for sicknesses including cancer. Granted, we may not get access to the absolute best care but does anyone care to offer a rebuttal because the argument goes, as far as I can tell in America, too many people go bankrupt for serious illnesses.

      1. Well, if you don’t have insurance, and you come down with a long-term health issue that requires expensive treatment, then you can go bankrupt. In the same way that, if you don’t insure your house, and it burns to the ground, you could also go bankrupt.

        It’s a risk you take, and of course the entire concept of Progressivism is to prevent anyone from ever suffering consequences from taking a risk. Much better to die on a waiting list. That isn’t a risk, that is just the natural order of things in the nanny state.

      2. I’m becoming a broken record on this, but if the goal is simply to prevent people from going into economic ruin because of catastrophic health costs, there are far, far better strategies than single-payer socialized medicine. Like a simple voucher system for the poor to spend on an open and free insurance market. Would that have some unintended consequences? Sure, but I’d wager quite a bit that such a system would be vastly superior to what we have now. But it would also involve people making their own (sometimes wrong) choices, and it would also involve someone else making a profit.

        1. ” it would also involve people making their own (sometimes wrong) choices, and it would also involve someone else making a profit.”

          Two things completely unacceptable to the left.

          People can’t make their own choices because they will make wrong ones and then we will have to pay to bail them out because of the fundamental moral principle that no one should be responsible for the consequences of their own actions.

          And people can’t make a profit, because “profit” is just money stolen from poor people by rich people, when the proper order of things is that the rich should be robbed for the sake of the poor.

  16. If you think Rachel`s story is nice, , 3 weeks ago my aunties neighbour basically broght in $5518 workin twelve hour’s a week from their apartment and the’re co-worker’s sister`s neighbour has been doing this for three months and got a cheque for more than $5518 in their spare time on their mac. apply the guide on this address, http://www.sea12.com

  17. until I looked at the draft saying $9846, I did not believe that my neighbours mother was like realie bringing in money parttime from their laptop.. there best friend started doing this for less than 8 months and resantly cleared the morgage on there cottage and purchased a new Lexus LS400. I went here, http://www.up444.com

  18. The most damning indictment of Canada’s health care system: their life expectancy is stagnating at a dismal #11 in the world, while the US holds steady at an impressive #40.


    1. Canada is basically full of Asian and White people.

      The US is full of Hispanics, Whites and Blacks.

      On that alone the life expectancy is going to be greater in Canada.

      The real damning thing is that Canada somehow provides health care to everyone in the country for less money than we do, where a good chunk of the country has no access to health care?

      Don’t have insurance? Well, you are just plain out of luck.

      Yes, people there have to wait longer to visit a doctor. But people in the US can only see a doctor quicker because what, 15% of the country can’t see a doctor at all.

  19. Actually…A May 2011 article in the Canadian Medical Association Journal (CMAJ) stated:

  20. Seems to me it is so depressing since no one explains how to take us to a free market medical care system. One idea is to end the income tax. This would remove the tax subsidies to job-based medical insurance and people would gravitate to individual medical insurance. Just as with life-insurance, they would buy non-cancelable insurance. Just as with auto insurance, people would pay for routine expenses out-of-pocket. For further info, please go to: http://electtherightcandidate……_Care.html

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