Sickness = Profit

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Description

Unpredictable chaos adds up to something over time. That’s David Smith’s story, and it’s also the origin story behind our broken health care system. This week, we explore why sickness pays and health doesn’t, and how we got here in the first place. Our guests this episode are economic historian Melissa Thomasson, health care journalist Elisabeth Rosenthal and futurist Ian Morrison.

Transcript

SPEAKERS

Dr. Elizabeth Rosenthal, Ian Morrison, David Smith, Melissa Thomasson

David Smith  00:00

Hey listeners, THE COST OF CARE is a 10-part series. We think it’ll make more sense if you start from Episode 1 So go back, start there, and we’ll be here when you’re ready. I got into healthcare completely by accident. Back in college, I actually wanted to be a godless investment banker because that’s where all the money was. After graduation, though, I got an unexpected invitation to share the stage with a guy named Mike Leavitt, who had served as a governor of Utah and was the Secretary of Health and Human Services for President Bush. And despite giving a terrible talk, because I knew nothing about health care, he offered me a job. That eventually brought me to Chicago, where I started to understand the importance of health versus healthcare in a really different way.

David Smith

I could look around the city of Chicago and see my own story reflected in an environment that looked very different from where I grew up in Utah. I saw entire communities dealing with this intergenerational decay, driven by many of the same factors I recognized from home, death, depression, drug use, chronic illness, all under the surface of 400 years of institutional racism. And this experience, along with all the twists and turns and traumas of my own past, solidified this passion, and it really brought me to where I am today. Where I get to work on projects around Medicaid and mental health and addiction. But I’m also brought face to face with a system that respects no one, rich or poor, black, or white – no one.

Dr. Elizabeth Rosenthal

I hear from patients who are like googling hospitals as they’re in the ambulance to see if it’s in network or not, you know, it’s that old saying, you know, you can’t put a price on your health. Well, if your kid develops a serious cancer or neurologic disorder, what price wouldn’t you pay?

David Smith  02:20

I’m never more aware of how irrational our healthcare system is, or how irrational I behave as a consumer in that system, than when I think about my three kids. If my wife burst in here right now and told me my six-year-old son had just passed out and was having a seizure. I am off this phone, I am in my car, and I went to a hospital in six minutes. I am walking through brick walls to get him to see somebody, don’t talk to me about benefits. Don’t talk to me about insurance. Don’t talk to me about cost. What’s wrong with my son? It’s health. None of us are rational. The problem is our system is set up to exploit that fact. It’s literally designed to keep us in the dark and profit off of our vulnerabilities.

Dr. Elizabeth Rosenthal 

You know, the way our system works at the moment, sickness pays and health unfortunately doesn’t.

David Smith 

We’ve debated healthcare in this country for decades, the players change but the talking points pretty much stayed the same. But the truth is, we all seem to agree on one thing, and that’s the current system sucks. Like really sucks, like Game of Thrones series finale level of suck. And every time we’ve tried to fix it, we somehow just make it worse. How did we end up with the most expensive but worst performing health care system in the world? Like we’re America, wasn’t designed to work this way or did it just kind of happen over time? This is THE COST OF CARE. I’m your host, David Smith.

David Smith 

One an example of how badly our system is broken. Look no further than this past year.

Dr. Elizabeth Rosenthal 

COVID was kind of a stress test for the US healthcare system. And it failed miserably from A to Z, and it continues to fail.

David Smith 

This is Dr. Elizabeth Rosenthal, she’s Editor-in-Chief of Kaiser Health News, a contributing op ed columnist at the New York Times and author of the phenomenal book: An American Sickness. Seriously, I’ve read the book twice,

Dr. Elizabeth Rosenthal 

I kind of had hoped that the book would be irrelevant by now that at least some of the things that I noted in the book would have been solved. And a few of them have been, but by and large, most of the problems at highlights have only gotten worse in the last four years. So while I’m glad the book is still selling, it’s a little depressing.

David Smith 

Well, I, one of the thoughts I had as I was reviewing it, is if you look at the challenges with the health system that you chronicle so well in the book, and then we think about the last year we’ve spent as a country navigating this pandemic and how ill equipped our system was and is for dealing with that kind of thing. And then we see the outcomes we have compared to other parts of the world. It’s just really shines a light on how broken we are. What have your reflections been over the last year?

Dr. Elizabeth Rosenthal  06:37

Yeah, I think it’s been very depressing, because I think one of the most, you know, sobering statistics, I think about every day is that the total number of deaths in South Korea is 1,300. Total. In a nation of 51 million people. And look how much we’ve suffered. My mom died of COVID. It’s paralyzed our entire nation, we’re still not out of it. And part of the reason we’re all going so crazy about vaccines in the US, is because we’ve done such a bad job from A to Z, that our only salvation at this point is to get vaccines into arms. You know, it’s just we’re desperate because we’ve so backed it up. And there are reasons that are very connected to the way we’ve allowed a fully commercialized healthcare system to burgeon in our country while allowing public health and public health systems to kind of, you know, catches catch can.

David Smith

One phrase we’ve all heard a lot over the course of the last year is public health. Public Health is rarely defined. Back in Episode 1, we talked about prioritizing health versus health care. That’s the public health approach. Public Health is rather than just focusing on how we treat people once they’re actually sick, we’re trying to prevent them from getting sick in the first place. And that means promoting things like wellness and preventive care, and supporting communities while encouraging healthy behavior. And that sounds great. But keeping people healthy, doesn’t make a lot of money. What does make a lot of money? Well, sickness, disease makes a lot of money. And if you’re wondering why our system is so much more commercialized, so much more focused on making money than other systems across the world, it ultimately comes down to how we access the system itself through insurance. 50% of Americans access the system through their employer.

Dr. Elizabeth Rosenthal  08:49

Sometimes I’ll call employer sponsored insurance – the original sin of health care.

David Smith 

I have never heard that – I love that.

Dr. Elizabeth Rosenthal

That sounds bad because you know, I have great insurance and I’m glad my employer provides it but it has ultimately resulted in very uneven coverage and all sorts of absurdities. We run this thing at Kaiser Health News with NPR called the bill of the month. And last month, it was about a couple. One had good insurance one had bad insurance. They had a baby, and they thought they could choose that the baby would go on the good insurance. But no because of something the insurance industry has invented called “The Birthday Rule”. The baby had to go on the bad insurance. So like you can name your baby whatever you want, you can pick your pediatrician, but your health insurance, you’re stuck.

David Smith 

So how did we get stuck with this system?

Melissa Thomasson 

Let’s roll back, all the way to like Circa 1900s so the turn of the 20th century hospitals were not very pleasant places a lot of doctors never even learned in a hospital.

David Smith  10:07

That’s Melissa Thomasson. Melissa is an economic historian at Miami University in Ohio. And she’s an expert when it comes to untangling the long, complicated history behind our messed-up system. In the early 1900s, medical care wasn’t that expensive, because frankly, it wasn’t very good. People didn’t want to pay a lot for lotions and potions or the occasional snake oil. But then we started getting good at medical care and things changed.

Melissa Thomasson

First of all, right around the beginning of the 20th century, we see a lot of technological advances in germ theory and science, and particularly in medical schools in Europe. And clearly the advent of sulfa in 1937 is a pretty big deal. You know, before that you die of, you could die of sepsis from a blister. In fact, in 1924, Calvin Coolidge, his son, John, died from a blister that got infected when he was playing tennis on the White House tennis courts without socks, right? I think about how many times I’d be dead. If I had, if I had an infected blister.

Melissa Thomasson

I mean, seriously, whereas 12 years later, FDR’s son was a junior at Harvard had strep throat, it went septic, he thought he would die. But he was one of the first people treated with sulfa. And he recovered, you know, just in a dozen years. So he really saw a huge shift in what medical care could do for you. But like today, as medical care got more effective, it got more expensive. As more people were going to hospitals, and they got, they started experiencing these bigger hospital bills, some of them couldn’t afford it. And the hospitals were trying to think of creative solutions.

David Smith  12:04

One of those creative solutions came from Baylor University Hospital in Dallas, Texas. They approached a group of public-school teachers with an offer.

Melissa Thomasson

And they said, What if we offer like a prepaid deal, right? So we’ll just charge these teachers 50 cents a month, and $6 a year. And if they need to use the hospital, well, we’ll give him three weeks of care in the hospital at no additional charge. So this was an employee benefit, which is one of the first broader scale offering of this kind of insurance we saw there.

David Smith 

This is “the original sin” that Elizabeth mentioned.

Melissa Thomasson 

This idea of just charging little amounts to everybody working for employers, really, honestly spread like wildfire. Some, you know, maybe just shy of 10% of the population had some sort of would consider modern medical insurance in 1940. Where on the eve of World War 2, what happens when the war hits is that everyone goes to war. And at the same time, we’re ramping up production of munitions and tanks and uniforms for soldiers and everything else. And the unemployment rate falls below 2%.

David Smith 

While Americans were fighting abroad in World War 2, there was a different battle at home for workers. The country was coming out of depression and men were being sent overseas. So businesses were naturally desperate for employees. Now, in normal times, if you want people to come work for you, instead of someone else, you simply offer a more money. But these were not normal times. It was wartime. And President Roosevelt had just announced a wage cap.

Melissa Thomasson

And so instead of competing on wages, which they couldn’t do, they started offering these various perspective workers really generous fringe benefit packages.

David Smith  14:06

Everyone was making sacrifices for the war effort. And that meant rations and taxes, lots of taxes. So it was a nice perk when the IRS decided employer contributions to health insurance were tax free.

Melissa Thomasson 

And so if you think about it, if you’re a firm, you can pay a worker $1 in wages, and the worker takes home, let’s say 80 cents after he or she pays taxes. But if you pay a worker $1 in health insurance, the worker gets the whole dollar. And it really led to growth in the market. But at the same time, there’s a lot of growth in demand, because now we have not only sulfa but we have penicillin, we’re seeing more vaccines, right? The vaccine for Polio in the 1950s. And it is really the period of the miracle of modern medicine. So we have more companies willing to offer insurance. Providers trying to get in on it tax breaks for insurance and people really see an effect of medical care for the first time, really in the 20th century.

David Smith 

Which brings us back to Dr. Elizabeth Rosenthal.

Dr. Elizabeth Rosenthal 

After World War 2, when there was intense competition for workers, it was seen as a benefit. So a lot of companies started offering health insurance as a benefit to attract employees and great who wouldn’t want that as we’re getting all these medical wonders. But what evolved over time was the way insurance works is the consumer doesn’t feel how much a thing costs, right? So eventually, you have Medicare, which is insurance for the 65 and over and disabled people, and which is good again, you know, good thing for to have Medicare, but people don’t see the cost rise.

Dr. Elizabeth Rosenthal 

And as healthcare itself becomes more of a business, you know, if people don’t react to costs, if they’re not price sensitive, then a good business person goes, well, why not just double the price or triple the price, or a thousand times the price? And basically, that’s what’s happened. And over the few decades, the prices just went ballistic, in part, you know, because the treatments were better, like MRIs are amazing. PET scans are amazing. But there was no like, thought about what should it cost or what is anyone willing to pay? Insurance just paid it.

David Smith  16:34

What we’ve essentially created is one half of our nation’s health care system is funded by government. And one half of our nation’s health care system is funded and administered by employers. And the part that’s funded by government doesn’t reimburse at rates that are as high as employers have. And so over time, we have learned how to basically subsidize what we don’t think we make enough from government by driving up the cost on employer sponsored insurance. And so the social contract is really required, we keep doing the employer sponsored insurance thing. But those benefits come at a huge cost to employers and workers. And it’s made it difficult to get any control of the ballooning costs. After the break, we leave the history in the past and take a look at the healthcare system as it is today.

David Smith 

Hey, listeners, we want to hear your stories. Have you been hit with a surprise bill after a procedure? Did you have a run in with the health care system that felt infuriating or unfair? Or have you struggled to find in network providers in your area? Share your story now by calling 8334-LEMONADA. That’s 833-453-6662 or email us at costofcare@lemonadamedia.com.

David Smith  18:12

We’re back. When I think about the origins of our healthcare system, I’m reminded of this cool story of a little island called Surtsey. So in 1963, there was an underwater volcanic eruption off the coast of Iceland. And when really, really hot magma hits really, really cold water, it solidifies into this little mass instantaneously. Now, each individual explosion doesn’t amount to much, but add up enough of these explosions over a four-year period. And it eventually created one giant mass that pushed 500 feet above the surface. And by 1967, there’s an island there were there was nothing before. Fast forward 55 years and Surtsey, an island that literally came out of nowhere has a sprawling ecosystem with birds and seals and 67 forms of vegetation. It’s thriving.

David Smith 

I like this kind of story because it reminds me of my own. Unpredictable chaos can add up to something over time, and it’s a really good comparison for our healthcare system. That island was created through an uncontrollable and violent process. And our system was basically forged through a series of uncontrollable historical accidents. And guess what? Today both are falling apart. Surtsey is crumbling into the sea. And we have a healthcare system that costs Americans nearly $4 trillion every year.

David Smith

Per person, we spend two times more than every other rich country on health care, but on average, we die five years earlier. We have higher rates of suicide, drug overdoses and people living with chronic diseases. We spend double what everyone else spends, and yet we come in last on almost every measurable indicator of health. So, to think about this, I sat down with my friend Ian Morrison, and I tried to sum it all up in one question as maturely as possible.

David Smith  20:26

Ian, why do we suck at this so bad?

Ian Morrison 

[…] And let’s be clear, you know, we have the highest trained humanoids in the planet, we have the fanciest buildings, we have the most cutting-edge technology. It’s unevenly distributed and inequitably distributed for a whole bunch of reasons we can get into. And that’s the source of part of the problem, it seems to me that the lesson, one lesson from other countries is it’s better to give everybody access to something that’s decent than it is to do total head transplants for the few, right? That’s going to lift the average.

David Smith 

Maybe this all comes down to a misunderstanding of our priorities. In the last episode, we explained that the healthcare system is only responsible for about 10% of our actual health outcomes.

Ian Morrison 

Medical care per se, has perhaps less impact on health status than we give a credit for is kind of overrated as a contributor to human health. And, you know, it turns out I think, as we’re learning that, things like income distribution, and social spending has a lot to do with this on the one hand. So while we under or perhaps over invest in health, we under invest relative to those countries you cited in social spending. And that shows up in those aggregate performance measures quite dramatically.

David Smith 

Well, I want to, you just raise two critical things that I want to dig into a little bit. And the first one is around this notion of the amount we spend relative to medical care, the notion of overspending. I’m going to put quotes in that overspending on medical care. In my mind, it would be one thing if we were double the rate of other countries in our spending. But instead of living to 78 years old, or 83 years old, we were living till 90-91 years old, you could really think about ways to justify that expenditure.

David Smith  22:33

But the notion that we spend more to your point, we have incredibly sophisticated innovative cutting edge, leading the world equipment, clinicians, data, evidence, science, and yet we’re still five years behind everybody else. So these social factors, these other determinants that weigh in on health, how important are those versus medical care? Like, how much should we be spending on medical care versus other stuff?

Ian Morrison 

Right, right. Well, and I think that’s exactly the right question. And that would be absolutely nothing wrong with spending more if you are getting the yield, in terms of health status.. And I think that that’s your key point. And, and we’ve got obesity rates there double, which is really a societal failure, you know, and cultural failure with regard to you know, our food supply system and our eating habits. You know, and that shows up in all of the outcome measures you talk about. The other one is guns, and we just are unwilling to have the conversation.

Ian Morrison

I mean, a lot of suicides are because of the availability of firearms. I mean, I find it appalling that the second leading cause of death among children is gun violence. Until that point, I mean, just yesterday, or day before we got the latest life expectancy numbers, and we’re living, you know, where life expectancy dropped by a year for everybody. And it dropped more precipitously for African-Americans, which is horrible in terms of a testimony of both the inequality and the lack of performance […] for this COVID period.

David Smith  24:21

Let’s think just a little bit about other countries. You’ve spent time in Canada. You’re originally from Scotland. So you’ve experienced a couple of other systems. What would you say the comparison is between those systems and the US systems just as a patient, just as a consumer, what do they get right? And what did they get wrong? Economic stuff kind of notwithstanding.

Ian Morrison

Yeah, your question hits at the essence of it, which is it’s not just the de facto performance or economics of the system. It’s the culture and politics and societal kind of values. That you know, the system is embedded in, you know, we’re not British, we’re not Canadian, I think we’ve got to accept that and pandemic has really underscored this.

David Smith 

You know what? That that’ll go on the cost of care quote, board, we’re not Canadians, we’re not British. There is something about this idea of finding a uniquely American system that can somehow be compatible with our ethos, our philosophy, our culture, our values, can push us to be healthier and live longer lives, but also doesn’t result in us spending two times as much for five years less of life. Yeah.

Ian Morrison 

Look, the Canadians, let’s start with them, are absolutely proud and fierce defenders of their system. I mean, in surveys, if you ask Canadians Would you rather have the American system of the Canadian system? It’s 90 to 9 in terms of support for the Canadian system, now, notwithstanding they see as flaws, you know, and the flaws in Canada in particular have to do with waiting times for specialty appointments. And that’s a real deal. It’s not, it’s not fabricated. It’s partly however, compensated for by absolutely zero barriers, financial barriers to entry for Primary Care Access. And so Primary Care Access is reasonably good and free effectively, at the point of care. Now free in the sense you’re paying taxes for it.

Ian Morrison  26:35

Canadians do not worry about the financial consequences of medical care, to their families. Maybe for long term care, which is very similar to the US they do but not for acute care. The UK is actually another example where the Brits for all of their political divisions even, you know, even a conservative government would find it enormously difficult to completely undermine the NHS and use kind of, quote unquote, market forces to reform every attempt has been done to do that. The British rise up. But the downside of the NHS, you only have to be in London a week and there’s a front-page story about some scandal in the NHS about screwing up something, right?

Ian Morrison

So there’s this love hate relationship where they celebrate it, but it’s also something they complain about. And look, the Brits like to queue up. I mean, they like to mourn and they like to get in line. So they don’t worry so much about that stuff. And they actually, the NHS for the money is pretty bloody good at delivering ubiquitous primary care with reasonable access to specialty services.

David Smith  28:04

Yeah, well, and so let’s just say we took the functional equivalent of the NHS, the National Health System in Britain, and we just plopped it in America. Congress and the administration. Passed everything needs to be signed and we have it on the ground and working, what would work well here, and what would just be a colossal failure?

Ian Morrison 

Yeah, I mean, as a thought experiment to imagine something like the NHS in the hands of the US Congress, it would become the mother of all pork barrel deals, right?

David Smith 

A lot of consultants

Ian Morrison 

Yeah. Oh, God. I mean, the politicization of the both the reimbursement process and, you know, in the hands of an American Congress, I think the NHS would it be a complete bloody disaster. It’s bad enough in the UK, the way is politicized, but God knows what would have happened if it was solely under the control of Congress.

David Smith 

The politics of this issue have become so toxic that it’s hard to imagine politicians playing a role in the solution. It’s not impossible, but it sure feels that way. It’s important to remember that despite all the arguments about keeping government out of health care, the US government is already totally entangled in the system. It’s just not happening efficiently. After the break, we’ll talk about how this inefficiency is driving up prices for everyday Americans.

David Smith 

We’re back with Ian Morrison. Why are prices so much higher in the United States, compared to other places? What is driving that?

Ian Morrison

Well, I mean, the short answer is prices everywhere else are regulated by government, right? I mean, and most other states drums are structured towards either monopsony, which is kind of a fancy word meaning a small number of buyers. And in the case of the Canadian system, one, you know, one purchaser being the government, or all a […] you know, a small number of powerful buyers, as in the case of Germany where the plans coordinate, but there is some de facto regulation of the prices. So it’s not a market driven price. And we, on the other hand, have about half of Americans getting health insurance through their employer. And that’s where the big price differentials are, the price differential between what Medicare pays and what the National Health Service pays effectively in the UK, or Canada, is not as dramatically different, where the differences are very wide, is the price differential with private payers.

Ian Morrison  30:57

So you know, a hospital will be charging 200% or 300% of Medicare, to its commercial patients. That just doesn’t exist in other countries to the same extent. If you look at the difference, it’s not that we get more stuff in this country, we don’t get more doctor visits, we don’t get more hospitalizations, we don’t get more bad days, we get slightly more fancier diagnostic procedures per 1000. But not compared to the Japanese, or the Germans. What is without doubt true is that we pay much, much higher prices for the same thing. And the people who get who deliver the service get much higher incomes. And that’s particularly true of, you know, everybody in healthcare, including consultants like us. But it’s especially true of specialist physicians, and an administrator especially, I mean managers in the healthcare make a lot more money, far away than they do in other countries.

David Smith

So, Ian, you’re a fellow economist. And so I’m going to ask kind of a core economics question. We have long had a debate in this country and attention around regulated prices and all kinds of industries, but certainly in healthcare, and competition. And there is an American ethos that there’s something deep in our DNA, that tells us free markets, that that kind of behave in a normal way are the best means of rationalizing prices. Why can’t competition help us get out of this?

Ian Morrison  32:50

Well, I think that’s a very key point. And it relates to your observation about the at the core here is culture. You know, one of my cruel jokes is Americans like to compete, give them what it doesn’t do them any good. Right? You know, I mean, it’s, I mean, it’s true, it’s sort of like, we think that it’s a good idea to compete, you know, and, you know, build up the capacity of both Stanford and UCSF within 50 miles of one another. Whereas in other countries, they say, No, no, no, we’re gonna have one big academic medical center to serve that population. It’s, you know, if you look at other countries, the culture and the politics and the political economy of those countries have enabled them to basically come down much more in the lane of regulated prices and not look to market forces so much.

David Smith 

What has been the problem with consumers having skin in the game? Is that cannot ever be workable? And what would have to happen for consumers to drive competition?

Dr. Elizabeth Rosenthal 

Well, I mean, you know, there’s been a lot of buzz now about price transparency, and that’s part of it and quality measures. So if you give patients price transparency and quality measures, they’ll be able to make better choices. And that’s true in some sectors, like, you know, a vitamin D test is a vitamin D test wherever you get it done. So, it will be the difference between $18 and literally $800 in some places, so huge price variation. So simple things like that can be addressed by transparency and information.

Dr. Elizabeth Rosenthal  34:32

The problem is that, you know, some things are really hard to know if you need them or not if you don’t have medical training, and someone tells you, you need a stent. I don’t know, do I really need a stent or not? You know, you’re kind of at the mercy of what the medical profession tells you need and you will don’t know how much it costs. You have no discretion; you can turn down some things but then they’ll probably ask you to sign a form saying it’s against medical advice. So you can’t be a good consumer, you just can’t, with many parts of healthcare.

David Smith

Right. It’s difficult to behave as a normal consumer in this industry, because you don’t have the decades long clinical training that a doctor has. So there’s that information gap that you have with a doctor. And it’s healthcare. Who behaves as a rational consumer, when you’ve got to get to the emergency department and have something very urgent addressed or you’re dealing with a chronic disease.

Dr. Elizabeth Rosenthal 

Yeah. And sadly, some Americans have to, you know, I hear from patients who are like, you know, googling hospitals as they’re in the ambulance to see if it’s in network or not, you know, that’s nuts. And you know, how can you, you know, it’s that old saying, you know, you can’t put a price on your health. Well, if your kid develops a serious cancer or neurologic disorder, what price wouldn’t you pay? You know? it’s not, it’s just not something you want people to have to say, gee, is it worth it to pay this much for my kid’s life, or my life?

Dr. Elizabeth Rosenthal  36:22

So I think, you know, this price transparency, and, you know, and more information about quality, that’s all good, but it won’t entirely solve the problem because you’re sick. It’s not like I’m going into a market and buying a loaf of bread and saying, oh, it’s really expensive here. So I’ll go next, you know, to the market across the street and buy another one and take my chances about whether it will taste as good. You know, this is life or death stuff.

David Smith

This is simple. Without information, we can’t make good choices. Next week, we hear how that lack of information leaves patients with insane medical bills or makes them too afraid to even walk through the doors in the first place.

Speaker 5

I heard from many other parents who had decided not to take their kids to the emergency room even though they were told to because they were worried about the financial implications. You have a system where patients are scared to use it.

CREDITS

The COST OF CARE is a Lemonada Original. The show is produced by Jackie Danziger and Kegan Zema. Our associate producer is Giulia Hjort. Music is by Hannis Brown. Executive producers are Stephanie Wittels Wachs, Jessica Cordova Kramer and David Smith. Help others find our show by leaving us a rating and writing a review. If you have a story to share, call us at 8334-LEMONADA or send us an email at costofcare@lemonadamedia.com. Follow us at @LemonadaMedia across all social platforms or find me on Twitter at @CHIDavidSmith. Lastly, we want to express our appreciation for the men and women who get up every day and work in this system with a passion for improving our health. We are grateful for the work you do. We’ll be back next week.

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