Obamacare Leaves Grady Hospital Facing A $45 Million Shortfall

WSB-TV is reporting that Grady Hospital is facing a $45 million shortage directly due to Obamacare:



  1. griftdrift says:

    From the accompanying article

    “The Affordable Care Act also cut federal funding for hospitals that care for the poor, like Grady. The intent of the law was to expand Medicaid to offset those losses.

    However, the U.S. Supreme Court left Medicaid expansion up to the states and Gov. Nathan Deal decided Georgia could not afford it.”

    Not commenting on Deal’s choice. Just pointing out, it was not a simple a = c equation, it was a + b = c equation.

  2. griftdrift says:

    I’m afraid I’m going to have to inject some more nuance into this.

    This is a perfect situation of a problem where we should be able to find a solution but solutions that require both sides to see the other are not very popular these days.

    As bgsmallz points out, we’ve known this problem is coming. There are plusses and minuses to both sides.

    The easiest solution is expand Medicaid. And there’s reason to think this would work. Medicaid (not Medicare, very important distinction) is actually very good at cost control. If you look at health spending over the past few decades, it is the one program where costs have been relatively flat. Better than medicare and even better than private health insurance. They do this through some pretty tough negotiating and limiting services to the absolutely necessary. So there’s a fairly good argument it would be the most effective manner to handle the gap of people who don’t currently qualify for medicaid but also don’t reach the 400% poverty level required for ACA subsidies to kick in.


    Governor Deal has a very real concern about eventual costs. The Feds only fund this expansion at 100% for a few years then it drops to 90%. The other 10% has to come from you and me. In this age of lean state budgets, that’s a significant amount. Deal absolutely has a fiscal responsibility to consider the long term impact on the budget.

    But here’s the real deal.

    Grady has been a problem for two decades. Having two counties support it is no longer tenable. We are going to have to fix this problem one way or the other and it could be done in a way where bipartisan consensus would be reached.

    If we could just put aside the chest puffing and work on it like grown ups.

    • Dave Bearse says:

      Add in the millions, if not tens of millions, lost by other hospitals statewide, and a good part of the additional statewide Medicaid funding is offset.

    • Charlie says:

      Let me attempt to add some more nuance. The expansion of medicaid tends to help very large providers in urban areas, like Grady, where there is a large amount of poverty and a large number of uninsured. Providers like Grady are treating these patients already, and thus, it’s money for something they are already providing for free (courtesy of local taxpayers). Thus, you’re shifting the burden over a larger pool of federal taxpayers. Grady wins.

      BUT, the effects in rural areas are very different. Not so much from the demand side, but from the supply side of healthcare. There aren’t large population bases to support health care services beyond general practices in rural America. What Medicaid does (and Medicare, and now to some extent the ACA) is to put cost controls on what providers can be paid for their services. Many of these reimbursements are set below cost.

      Now, let’s say you’re a young doctor just finishing your med school, have $100K+ in student debt, and need to go out and make some money. Where are you going to go? Ideally, you want to work in the wealthy suburbs where at least some of your patients still have private health insurance. Or, you can go for the guaranteed volume at a low margin of inner city patients. But, assuming you actually have to make some money to keep your practice open and pay your student loans, why would you choose a rural setting?

      The answer? Most aren’t. Rural areas are finding that even promises to amortize the student loans aren’t attracting new docs to their areas because they know that between Medicaid and Medicare patients that they will have to treat below cost, there aren’t enough patients left over to pay the overhead to get them to a business model that works.

      ACA and the general philosophies behind it are designed with urban areas in mind. Rural America will not be better off, and will likely be worse off, because there won’t be doctors around to provide these services to everyone with their shiny new platinum programs.

      • griftdrift says:

        So let me ask a question,, Charlie. And I will admit my ignorance in this area.

        What are the costs and what’s driving them? Drugs? Equipment? One of the things that I don’t think people understand is health care is inelastic and it’s market is completely distorted. Could we not attack the cost vectors to try to solve the problem? Won’t having additional consumer in via the exchanges force the market to adjust?

        And why could we not try a debt forgiveness program tied to service?

        It just seems crazy to not fix the big problem because we can’t figure out the way to solve the small problem. Especially when it appears we are not even trying to solve the small problem.

        • Charlie says:

          Debt forgiveness program tied to service? I’m told it has been routinely tried and it is not enough. It doesn’t matter if debt is erased if a specialist still can’t make a profit for his/her services. Even GP’s have great difficulty in many rural areas.


          This answer will of course depend on who you ask. Some will say tort reform will help (I personally don’t see this as a holy grail). Some blame drugs (again, not likely the biggest contributor and has almost nothing to do with a doctor’s profit margins).

          I think we do have a horrible administrative problem now, where about a third (stat I’m semi-remembering and semi-making up) of the costs are the administration between the provider and the customer. I.e., the various people at the doctors office and the insurance companies that push paper back and forth trying to figure out what will be reimbursed and when.

          About a year ago, Piedmont and Wellstar announced that they would be rolling out their own insurance program, aimed at taking a large part of the costs involved in these non-patient paper intensive activities (and costs). A government relations VP at another non-related major hospital told me he sees this is the next wave of the future as it’s likely the only real way to bend the cost curve.

          But again, that is a solution that works in suburban and urban areas. Much harder to do with small hospitals in rural areas.

          • Lea Thrace says:

            This discussion between you two is entirely too civilized. Where are the attacks and namecalling? No has been referred to as an idiot. Unbelievable!

            Too much reasoned discourse. I’m disgusted at you two!


            I appreciate both of your comments. You’ve both given me some new insight. Thanks gentlemen.

          • Jackster says:

            The other way to bend the cost curve? Making it cheaper to make doctors. Nursing is becoming more cost conscious.

            Promote the NP / PA / Midlevel provider to have a larger role in the mix – save the doctors for when you need specialists or to manage several chronic diseases at once.

          • saltycracker says:

            Good comments- the independent Doc is becoming rare. They are joining hospitals or very large groups associated with hospitals. The rural areas will become dependent on services from the big urban players with multi-location Docs.

            The folks of Cumming and Canton will get improved medical coverage with experienced (see that all the time) Docs of Northside. And it’ll shorten up the trips the mountain folks make to specialists now. Consider Piedmont locations from Newnan to Ellijay.
            If the market doesn’t support a hospital, they will open a clinic.

            Hospitals will also try to get a monopoly on the area if the locals allow it – as Cherokee did with Northside vs. Kennestone.

            The politicians will never be the smartest in the room, so why not just worry about keeping the fight clean and competitive.

          • MattMD says:

            People should also understand there is no enforcement of medical programs that are out there to help with the rural supply of doctors (like Mercer attempts do for instance). You can apply and interview like: “Oh no, I’d love to go out and treat the rural population”, but after your residency you can basically do whatever you want.

            Of course under served populations may also be defined as urban but their are way, way more doctors in the states urban areas like Athens, Macon and Savannah than many people realize.

            • MattMD says:

              Of course it should be obvious that no enticement in the world is going to work if you cannot keep up the business side of the practice.

      • Jackster says:

        There is also another hit in the form of Medicare reimbursemet reduction if those rural hospitals and practices don’t attest to meaningful use (Health IT initative).

        Those places typically don’t have the talent, broadband, and dollars to “survive” meaningful use. Therefore, they will get hit with reductions in:

        DSH funding
        MU reimbursement
        Stricter CMS guidelines over readmissions, which means they won’t get reimbursed for those who use the ER as their clinic, since you can’t bill for a readmit so close to a discharge.

      • benevolus says:

        I would think this would be easy to fix. Make a distinction between “rural” and other types of jurisdictions and set different rate caps.

        Of course “fixing” means “agreeing” on something, and that seems a bit out of reach at the moment.

    • Toxic Avenger says:

      One other nuance, grift.

      Deal could expand Medicaid for 3 years and then, if we can’t figure out how to come up with the 10%, leave it. It’s an opt-in, opt-out program; once you’re in, you can get out.

        • Or third option: premium support like Arkansas and Iowa have done. Or get really creative – high copays for the poor if you smoke to cover the other 10%. There are literally so many options and ideas out there that would work, and it’s so obvious to me that we’re going to do this anyway that it’s shameful and cowardly of Deal to hurt the poor by not doing it now for political reasons.

          All that plus if you believe the study the AJC wrote about recently, expanding Medicaid is at worst revenue neutral for the state when you consider everything. Finally – everyone who pays federal taxes in Georgia is subsidizing healthcare for the poor in other states but not getting any return for their dollar here. Isn’t that worth factoring into the “can’t afford it” calculus?

        • Jackster says:

          We opted out of developing transit and roads to keep up with growth, and we opted out of the program that keeps our kids educated at a very competitive rate.

          We also as a state opted out of taking care of our mental health patients who aren’t in jail, seeking to have a good ethics program for our elected officials, and curbing poverty.

    • mpierce says:

      If you look at health spending over the past few decades, it is the one program where costs have been relatively flat.

      "From 1971 to 2011, growth in Medicaid expenditures averaged 11.4 percent per year, and enrollment growth averaged 3.4 percent per year; the average expenditures per enrollee grew at an average annual rate of 7.7 percent. "


      • griftdrift says:

        Check page 6 of the report

        “In 1970, combined Federal and State expenditures for Medicaid represented 0.5 percent of gross domestic product (GDP), but this percentage grew to 0.9 percent in 1980, 1.2 percent in 1990, 2.1 percent in 2000, and 2.8 percent in 2011”

        Relative compared to growth in other sectors (medicare, private) in the context of percentage of GDP

        • mpierce says:

          I would be curious how CHIP has effected that chart. As of 2011 children were 50% of medicaid enrollees, but only 20% of expenditures. Elderly were 9% of enrollees and 20% of expenditures.

          2011 Expenditure per enrollee
          child $2,851
          adult $4,362
          disabled $17,958
          aged $15,931

          The demographics for medicare and private sector are much different.

          • John Konop says:


            ……..children were 50% of medicaid enrollees, but only 20% of expenditures. Elderly were 9% of enrollees and 20% of expenditures….

            This has to do with end of life care cost. The majority of healthcare is spent on your last 6 months of life. And many times people do not the want the procedures ie end of life directives would be a major fix…..

            • mpierce says:


              My comments were in response to grift. I understand the disparity in cost. The point is child enrollment in medicaid (as a % ) has been increasing. Elderly enrollment (as a %) has been decreasing. The disparity in costs by each group combined with the change in demographics of the enrolled provide for a misleading overall expenditure growth chart.

    • John Konop says:


      From what I have read the following are big drivers in the healthcare system:

      1) Drug prices, VA pricing would fix that problem for exchanges…….

      2) End of life care……end of life directives would be a major fix…..

      3) Emergency rooms used as a doctors office huge problem…..dial doc in the emergency rooms major fix…for non emergency care…..

      4) Self insured HSA style group exchanges about a 20% savings…..

      5) The billing systems need real help………….

      • griftdrift says:

        But John, that’s much broader than what Charlie is talking about. Don’t disagree that those are the traditional drivers that warp the larger healthcare market.

        What I’m really curious about ( and Charlie explained part of it ), is what drives costs in a rural private practice. The part that Charlie indicates are causing Doctors to not open practices in those areas. I need to understand the business model better.

        • Charlie says:

          Again, to be clear, it’s not the “cost” of delivering medicine in rural areas I’m talking about. It’s the revenue stream that is artificially limited below an amount that would cover these costs. When every government solution seems to rely on lowering the reimbursement to providers (with most docs now saying that both Medicare and Medicaid have reimbursements below cost), then why would doctors want to continue to supply this service?

          Yes, if you could lower the costs it would make it more attractive. But the bigger and more immediate point is that we’re giving more people “access” to healthcare on the demand side while simultaneously removing that access to that health care from the supply side.

          • griftdrift says:

            Okay. I understand your point but you’re still going to have to explain it to me like I’m a third grader.

            ( and I’m just going to make up some numbers )

            I understand that medicaid may limit a hip replacement device to $8,500 where the cost is $10,000, putting the doctor in a bind unless they can make the margin elsewhere. But, my real question is not why is Medicaid keeping the revenue underwater ( obvious answer, it keeps their cost down ), my real question is why does the hip replacement device cost $10,000?

            It’s not an open market. You can’t just go down to the hip replacement store. Therefore there must be something else that is driving and we should be able to find a way to put market forces on it to lower the cost.

            ( Full admission, I read a NY Times piece on this and may partially know the answer but I’m curious where this goes )

            • Charlie says:

              The cost side is an entirely different exercise and is in part addressed above by the reference to the tremendous overhead both at the doctors office and the insurance companies who trade a ridiculous amount of info back and forth as they haggle over who gets paid what and when.

              There are many other embedded costs (such as the lack of competitive bidding for drugs, import restrictions on the same drugs sold cheaper in other countries, etc.) And yes, they could be attacked to help solve this problem.

              Included in my overall point is that they haven’t been. It’s much easier to just keep taking a percentage or two out of the doctors pockets. It’s been done many, many times (I seem to recall that being one of the issues in the 95 shutdown).

              We’ve now cut well below cost for reimbursements for a majority of the patients that these doctors see. And that has been the overall “fix it” strategy from the Feds, on both the R and D sides.

              The thing to remember here is that we’re talking about the rational behavior of doctors at a microeconomic, 101 level. They as individuals are price takers on the cost side. They can’t affect the costs much if at all, and they’re being mandated what most of their revenue per transaction will be. When those numbers don’t add up to a profit, the “firm” – in this case the doctor – exits the field.

              • griftdrift says:

                And our points are drawing closer together. They can’t affect the cost side because it’s not really an open market right? There’s little real competition in their supply chain?

                Bottom line it’s a problem. And based on our conversation, there’s ways to attack it. For myriad reasons we just don’t seen to be willing to wade into it.

            • mpierce says:

              my real question is why does the hip replacement device cost $10,000?

              1.”It’s not an open market.”
              2. Insurance. The costs aren’t directly passed to the consumer.
              3. Risk. (example)
              4. I’m sure the medical device tax won’t help.

        • John Konop says:

          You might find this interesting! A key point is good paying manufacturing jobs going away created a lot of the problem.

          ……rural areas have witnessed a significant decline in manufacturing jobs and a rise in
          service sector employment, losing jobs with higher rates of employer-sponsored health insurance while gaining jobs
          with much lower rates of employer-sponsored coverage.4….

          ………The rural economy is largely based on self-employment and small businesses. Since 1969, the number of selfemployed
          workers in rural areas has grown by over 240 percent (by comparison, rural wage and salary workers
          witnessed only a 61 percent growth over the same period). 5 With an economy dominated by small businesses and
          self-employment (as well as seasonal and “patching” employment), rural people are generally less insured, more
          underinsured, and more dependent on the individual insurance market. While rural residents have higher rates of
          uninsurance, the existence of underinsurance may be as large an issue. There are twice as many underinsured in
          rural nonadjacent areas (those areas not adjacent to a metropolitan area) as in urban areas, and the challenges
          faced by the underinsured are ultimately similar to those of the uninsured.6 Rural nonadjacent residents are
          responsible for nearly 22 percent more of their total health care costs (premiums and out-of-pocket costs) than are
          urban or rural adjacent residents.6 Further, the odds of rural nonadjacent residents being underinsured are 70
          percent higher than for urban residents, suggesting the “actuarial value of private health plans held by rural
          residents is lower than for urban residents.”6………………….

          …………With a population that is older, poorer and with less employer-based health insurance coverage, a larger segment of
          the rural population is dependent upon public health care programs such as State Children’s Health Insurance
          Programs (SCHIP), Medicare and Medicaid. The number of rural non-elderly residents covered by public health
          insurance programs has increased by nearly 122 percent since 1987; nearly a third more rural people are covered by
          public plans compared to urban residents.4 Yet many rural people and businesses are not eligible for these public


  3. DeKalb Wonkette says:

    I so much appreciate all these nuanced comments! It’s the reason that Peach Pundit is my “home page”.

    Whatever can be said of the ACA and it’s Medicaid expansion option, there is one dimension that is frequently overlooked: The expanded coverage population would include the ex-offender population along with those sentenced to alternative treatment programs by accountability courts (even the substance abusers could be deemed “medically fragile” for coverage).

    Given the Governor’s commitment to reducing incarceration and recidivism, whatever Georgia’s cost in expanding Medicaid could be offset in criminal justice spending.

  4. Charlie says:

    Okay, now let’s talk about the “lack of competition” (continuing the conversation where Grift and I are talking and somehow I’m pretending to be the expert here when all I really know is that this whole system is a damn mess),

    We’ve established that doctors are mostly price takers in this space, using the traditional microeconomic model of a firm. That is, their costs are fixed by others (drug companies, hospitals, other forces within their space) and their revenues are increasingly capped by government for medicaid and medicare patients and by insurance companies for those with private insurance).

    Grift concluded up above that there is little competition in the supply chain, and that is a large part of the problem. (or he was summarizing what I said by saying that).

    Now is where philosophy and ideology come into play. We know there’s a problem (almost all of us who are paying attention can admit that). We now are arguing over how best to solve this problem.

    One school of thought is to eliminate all competition. In short, this would be the single payer model. Everyone gets all the access to all the “free” healthcare they need, and the government pays.

    Great collectives often sound great on paper, but we’re seeing problems as we started this conversation as to what happens when we start down this path. The government designed system here has the unintended consequences of creating shortages in rural areas because their assumptions didn’t seem to take into account how the markets are working in these areas.

    Then you have the perfect competition model. You get government out of the way and let the “market” fix everything. The problem here is that at some point (age), medical insurance is no longer “insurance”, it’s a fixed payment for certainty.

    With modern medicine, gene tracking, and electronic medical histories, everything becomes a pre-existing condition. Those underwriting policies are getting very adept at excluding people who appear quite healthy and have no active conditions from insurance. And then we still have the problem of these same insurance companies removing the patients from the cost-purchase decision when health care is actually delivered.

    A lot of the current solution on the right is focused on trying to get back to where a patient and a doctor actually have a market where they are not price takers, but actively involved in the decisions of the transaction between the two that determines the price. A model based on Health Care Savings Accounts backed by a catastrophic insurance policy is what many propose to help start pressuring prices down via consumer powers of negotiation. I would have to say that this would probably work on the younger half of the population.

    But as we’re aging, we’re also getting to the point where medical technology could keep us alive almost in perpetuity. But, problem is, that’s not cheap. This is where end of life directives are extremely important. There comes a time where the patient needs to be able to say “no more, let me rest in peace”. But, this has to be done by the patient ahead of time. Not by a frightened, loving, grieving, family member who is watching a loved one slip away but doesn’t want to be the responsible one for saying exactly when.

    In short, there are a mess of issues here. Not all of them are directly economic considerations. But how we pay for an increasingly aging population’s medical care is perhaps the greatest fiscal challenge of our time. It won’t be an issue settled by one blog post.

    • George Chidi says:

      Charlie is wise.

      I favor single-payor because the empirical evidence around cost and service delivery from other industrialized nations indicates to me that it’s the better play. Health care as a percentage of GDP is absurdly high in America, and the outcomes are lower. I’m not particularly ideological about it: for me it’s just the math. India’s transportation system is a giant jumbled mess and eats about as much of its GDP as health care does for ours, and my argument there would be to deregulate and improve the court system so contracts are more easily enforceable.

      But I think Charlie has hit the nail on the head about the American health care problem, talking about the less-plainly rational economic issues driving some of the cost here. For example, defensive medicine is real, and a real problem, and also not particularly rational behavior when comparing risks and benefits for the doctor, the insurer or the patient. The recent studies about treatment for colorectal diseases bears it out.

      The end-of-life decisions people expect their family members to make on their behalf can’t be expected to be particularly rational, either. There’s a reason why doctors as patients, more than any other group of patients, tend to reject drawn out and expensive life-saving treatments — they’ve seen the indignity and futility of it up front and can make a more rational decision.

      Mistrust and fear. Ultimately, that’s what’s driving our costs through the roof. Fear of loss. Fear of blame. Fear of failure. Insurers mistrust of patients — the question of adverse selection and asymmetrical information. Patients mistrust of their doctors — the agency problem. Doctors mistrust of insurers — often more adversarial than even the patient-insurer relationship.

      The problem with the ACA isn’t that it went too far. It’s that it’s only pecking at the surface of a deeper problem. I fear that the way this all came through is going to poison the well for continued reform for a generation, short of the emergence of an overwhelming political majority in one direction or another.

    • saltycracker says:

      We’ll said. Costs will continue to escalate with “advances” not just for the aged but for hopeless situations. More children every year are brought into the U.S. to advantage our system.

      The decisions are tough and while decisions made by the distraught are unwise, they will be worse by political policy makers. Living Wills cannot be mandated and will not be in the majority. What would be rational is circumstances where a panel involving experienced providers – doctors, nurses – not insurers, lawyers or politicians – determine it is time to stop insurance or public pay. When the docs and staff beg the decision makers to let it go, we’ve done our best, go home or call in hospice, and they refuse, coverage should end.

      Not a death panel but an end of coverage.

      • John Konop says:

        The biggest issue with end of life cost is Medicare/Medicade which is not private insurance ……this idea was proposed and it was called a death panel.

        • saltycracker says:

          Death panels: myth

          But the conversations about the makeup of a panel to reduce costs would be the wrong folks to involve in cutting off Medicare/Medicaid payments when a situation is deemed totally hopeless and inhumane to continue. But I’d support one with the right makeup and a limited scope.The patient or those responsible would then have to find a charity hospital or use their money to continue.

          Also, these extraordinary situations are probably not a big percentage of the total costs at the end as most of big expenses would be approved as having potential. Suggesting, there is not much that can be done unless we open the doors of competition and innovation to get some of the related costs down.

          But immigrating those needing extraordinary health costs in the name of humanity might need revisiting or directed to charity hospitals or revisit making a multi-billion dollar business out of hoverrounds for the grossly obese or revisit maintaining a cottage legal, medical & middle man industry for getting folks on disability or revisit our selective enforcement on tens of billions of fraud, probably identifiable with the right software & computers or better yet, privatizing.

          • MattMD says:

            I don’t understand your last sentence. What exactly do you want to “privatize”?

            I’m not trying to be a jerk but run-on sentences make horrible paragraphs.

            • saltycracker says:

              Sorry. Rushing along. It was a paragraph of the first order.
              Privatizing was a reference to regulation not ownership. With the mess the govt is making out of Medicare & Medicaid it is my fantasy that they stick to regulating and defining insurance parameters that the govt financially supports. Why can’t they pay the premiums for such coverage for whatever parameters they set and we can choose the provider and pay other options. Our secondary providers can continue as now if we choose.

              I realize this is doubtful as our legislators, working with healthcare lobbyists would fight to the death to keep the industry from being competitive.

          • John Konop says:


            In all due respect I do not understand your answer. My point is fairly simple and logical, end of life cost is past on to Medicare, which is the majority of money spent on a persons life. Do you support having a panel for Medicare/Medicade decide how much the tax payers will cover via end of life cost?

            • saltycracker says:

              I think it is very complex problem as end of life costs cover a very broad field. Old age is where the costs go up, for the most. I and my employer have paid into insurance all my life, used about zero and assume there will be some big bills down the road. I also have a living will so assume any big costs would be agreed to be a chance at maintaining some quality of life.

              I also have relatives that have done none of the above, one terminal that expects heroic action long after there is any quality of life left. Are these people a significant impact on the total dollars ? If so, yes, a panel is needed, but in every case I know of there are doctors and hospital health folks that beg the family to let it go. If that is a panel, I’m for it. Time to send them to a charity hospital. A panel involving insurers and administrators would be a death panel.

              But I’ll bet it is not a significant portion of the end costs, the greater share of these old age costs are probably those the Docs says..might help. Thus we might be better served understanding where and why the system is screwed up.

              I made other points of extraordinary medical costs that make no sense.

              • John Konop says:

                Below are numbers from 2009, so we know the problem is only growing.

                …………..Medicare paid $55 billion just for doctor and hospital bills during the last two months of patients’ lives. That’s more than the budget for the Department of Homeland Security, or the Department of Education. And it has been estimated that 20 to 30 percent of these medical expenses may have had no meaningful impact. Most of the bills are paid for by the federal government with few or no questions asked…………

                …….politically explosive one – a perfect example of the rising costs that threaten to bankrupt the country and how hard it is to rein them in……..

                ………Something like 18 to 20 percent of Americans spend their last days in an ICU,” Byock told Kroft. “And, you know, it’s extremely expensive. It’s uncomfortable. Many times they have to be sedated so that they don’t reflexively pull out a tube, or sometimes their hands are restrained. This is not the way most people would want to spend their last days of life. And yet this has become almost the medical last rites for people as they die.”……….


  5. DeKalb Wonkette says:

    Only one add to the Rx for catastrophic insurance and HSAs: Build up the primary health care system (federally qualified health clinics) where people can get preventive care and manage chronic conditions before they are out of control. This would be enough for most of us who are not aged or disabled. Not sure what the answer is for these latter but the current Medicare system is a clunker. Providers are incented to offer ever more specialist tests etc which lead to wildly out of control yet ineffective treatment as outlined in the Dartmouth Health Atlas. (http://www.dartmouthatlas.org).

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