7 ms·

I very much like free market. But here, the final consumer is not in a position to bargain prices when getting sick, which is a pre-requisite for a free market

I very much like free market. But here, the final consumer is not in a position to bargain prices when getting sick, which is a pre-requisite for a free market to function. Single-payer system works way better in that very particular industry, because both parties can now effectively negotiate. Example: GSK is selling Advair Diskus for $300 in the US, and the same Seretide Diskus for 30 euros in France. Because on one side, they negotiate, and on the other, the enact laws to prevent negotiations (see Medicaid). When you need that disk every month, it's a huge difference. I understand why this system is better for GSK, their shareholders and management. But why is it better for American people to persevere with a system where you pay 10, 100 times the fair price? And don't blame the lobbyists, they can lobby all they want, the voters are the boss. If the majority wants to stop paying 100 times what they should, if the majority is tired to go bankrupt when they get sick, it just takes to publically support a single-payer system, and to vote for that. Politicians will listen.

rm_-rf_slash 10y ago
Most Americans believe in a single-payer system. However, even if the Democrats made it a solid goal, the Republicans would essentially convey the message: "Sure, you can vote for the Democrats if you want, but be prepared for them to take all of your guns, force you to pay welfare for Syrian immigrants, and use your taxes to pay for abortions." Enough people would consider those things - even if they have an iota of truth - more important than universal health care, so they vote against the politicians who support it. This assumes republicans do not adopt a single payer system in their party platform. I think that assumption is plausible.
- snowwrestler 10y ago
  The argument against government single-payer is to imagine the politicians you dislike the most in charge of your health care. Would Democrats still favor single-payer if they knew that Republicans would get to make all the policy decisions about what is covered?
  - Nursie 10y ago
    Yet other countries seem to make it work quite well and keep it a-political. No party decides these things.
    - snowwrestler 10y ago
      Some other countries make it work. Other other countries have health care systems that are way worse than the U.S. So: it's good to know that things are different in other countries, but it doesn't actually address the point I was trying to make. Of course single-payer works if we imagine that things in the U.S. are different from the way they actually are. Lots of things work that way.
      - Nursie 10y ago
        I'm not aware of any countries where that specific aspect, choosing which drugs are available, has become politicised and toxic. I agree that the two-party adversarial politics in the US is poison though, and causes a whole lot of "this is why we can't have nice things" moments.
      - otterley 10y ago
        > Of course single-payer works if we imagine that things in the U.S. are different from the way they actually are That's a fantastic argument for changing the way things are in the U.S. It happens one vote at a time.
  - lintiness 10y ago
    more along the lines of: the government that can't seem to make anything cheap ever and that is mostly lying and full of shit all the time wants control of my WHAT?
    - ZeroGravitas 10y ago
      This is just a variant on "get your government hands off my Medicare". The healthcare "market" in the USA is deeply, pervasively and often bizarrely regulated by the government. Don't think of it as free market versus government regulated, because that's simply not true.
splintercell 10y ago
> I very much like free market. But here, the final consumer is not in a position to bargain prices when getting sick, which is a pre-requisite for a free market to function. Single-payer system works way better in that very particular industry, because both parties can now effectively negotiate. I am sorry but you don't like Free market. That's like saying "I love Hillary Clinton and I am totally with her, but I think Trump would be a better President than Hillary in every way because he is not dying". My friend describes this as a 'Sales Pitch argument' where you claim to support your opponent's position, but you actually don't. "I am all for Gays to be able to freely marry, but we gotta make sure that the kids they adopt aren't going to abusive homes because statistics say that kids raised by gay and lesbian couples don't do so well". > the final consumer is not in a position to bargain prices when getting sick, which is a pre-requisite for a free market to function. I don't know from where does this kind of faulty thinking originates. Lemme show you why it is faulty: The final consumer of food is not in position to bargain prices when he is hungry, which is a pre-requisite for free market to function. Therefore a single payer food system works better than a private food system. The final consumer of a gun is not in a position to bargain prices when his home is invaded, which is a pre-requisite for a free market to function. Therefore a single payer gun system works better than private market for guns. The problem is, you're not suppose to look for food only when you get hungry, or buy a gun precisely when you're getting invaded, you're suppose to do these things BEFORE you actually need them. And just like food (which you need daily multiple times) you buy in chunk. The whole system of food acquisition works out perfectly fine. Your rest of the comment is more to the point, and the way things are in America are antithetical to a free market in healthcare and pharma industry.
- snowwrestler 10y ago
  I agree with this, and I'll add that the system we have now actively prevents me from trying to apply price sensitivity. I have a chronic illness that requires me to take medicine every day; some prescription, some not. For the prescription medicine I get a prescription from my doctor. It does not tell me the price of the drug, nor does it tell me whether there is a generic available, or another brand-name drug with similar effect. Even if I ask, the doctor typically has no idea how much the various drugs cost, and which are less expensive. They just say "your insurance will cover this." I take it to the pharmacy. None of the pharmacies advertise their prices for this drug, so I have no reason to choose one over another. I fill the prescription and go to checkout. The price will be different depending on which tier the drug is on at my insurance company, the copay for that drug, or whether I've yet satisfied my deductible. The only way to predict these things in advance is to read through dozens of pages of dense literature from my insurance provider. And by the way, I have no choice in insurance provider because my employer only offers one. For the non-prescription medicine, the price is clearly marked in every store, and generics are clearly identified and merchandised right alongside the brand name. I have great opportunity to choose where and what to buy. And, no surprise, these are way cheaper than the prescription drugs. Keep in mind that my need for, and usage of, these drugs is exactly the same. But the price is radically different depending on whether they come to through the clarity of the market or the opacity of the current health insurance system.
replicatorblog 10y ago
The problem with the "can't negotiate" argument is that insurers have every incentive to negotiate on behalf of the patients they cover. And they have scale—United Healthcare covers more lives than the NHS. I worked at a startup that dealt with international reimbursement and we accepted less in France because it was just how it was done. We got paid much more in Germany and the UK. In the US we got paid a lot from some people and sold a very similar product to Walmart for 1/5th the cost. This was a small startup, not a global pharma company, though we worked with a few and saw similar patterns at play. History, as much as politics and economics, shapes the industry in profound ways.
- e40 10y ago
  The problem with the "can't negotiate" argument is that insurers have every incentive to negotiate on behalf of the patients they cover. And they have scale—United Healthcare covers more lives than the NHS. You would think, but they don't. That's the problem. Why? I don't know. Car insurance is a similar thing. My SO barely tapped the car in front of her at a stop light. No damage, even though the woman flew out of the car claiming her car was damaged (we have pics of no damage) and that her children were injured (two boys in the back seat without seat belts or car seats). My SO asked the boys if they were OK and they laughed and said "yes." So, a month or so later I get a call from the insurance company they've settled for medical bills of > $10k and damage to the car for ~$4k. I was livid and told them I wanted them to fight this fraud. Nope, they wouldn't do it. I begged the agent for 20 minutes. It's cheaper to settle. It would clearly be in the best interest of the insurance company to crack down on fraud, but they feel it's "cheaper" to settle and move on. I think the same mindset exists in the medical insurance industry.
  - supergeek133 10y ago
    Same thing happened to me with auto insurance. State trooper shows up, asks everyone if they are OK, doesn't take a report because no damage. A year later my insurance settles with the guy for $4k, and my insurance premium almost doubles. Medical insurance is the same because the insurer, the drug company, and the doctor ALL benefit from increased prices.
astazangasta 10y ago
Drugs are often covered by patent monopolies and do not operate in a free market.
- throwaway7767 10y ago
  I can't understand why this is downvoted. A product that can only be manufactured by one company due to patents does not have a free market. That's not a value judgement of the patent system, it's just stating the obvious. A patent is a legally enforced monopoly, so of course there will be no competition while the patent is in force.
refurb 10y ago
Example: GSK is selling Advair Diskus for $300 in the US, and the same Seretide Diskus for 30 euros in France. Because on one side, they negotiate, and on the other, the enact laws to prevent negotiations (see Medicaid). As others have mentioned, there can be a big difference between the list price and the actual price the insurer pays. The asthma market is highly contracted with big rebates going to payers. Second, Medicaid does negotiate. First off, Medicaid get 23.1% off of every drug, just to start with. Then they can negotiate supplemental rebates if there is a lot of competition in a therapeutic area. When you add it all up, Medicaid pays some of the lowest costs for drugs of any payer.
- coldcode 10y ago
  Medicare is the problem, Medicaid is allowed to negotiate.
  - refurb 10y ago
    Medicare Part D (prescription drugs) is entirely run by commercial payers who are allowed to negotiate (and do). Only Part B is limited from negotiating price, but discounts do happen in competitive markets and CMS captures those savings.
- bisRepetita 10y ago
  So basically, with a high deductible plan, I am getting screwed by my insurance company, because I do pay $300 for Advair out of pocket, instead of the negotiated price.
  - refurb 10y ago
    Correct! You are typically responsible for the list price, not the net price the payer pays. So, you pay $300 for the drug (list price). The insurance company uses that $300 to pay the drug company, which in turn, rebates $150 back to the payer. Pure profit! If you are just responsible for the co-pay it works better. You pay $30, the payer pays $270 and the manufacturer rebates $150. Overall, the drug costs $150, $30 coming from you and $120 (net) coming from the payer.
jmde 10y ago
The problem is that it is not actually a free market. The government grants monopolies to prescribers, restricting access that way, and to drug manufacturers, through the FDA, directly or indirectly (it's crazy to me that the government grants these monopolies and then complains when businesses take advantage of them financially). Then you have the insurers, who are not actually the beneficiaries of the product and who are therefore not in a position to fully judge the benefit:cost ratios of the products. To me, the problem is lack of competition. The government should remove or sharply curtail licensing laws, or expand them to other professions substantially, and eliminate or loosen drug schedules (the new kratom fiasco is just one example of many spanning decades of how inept the government is at regulating substances). Basically, decriminalize and deregulate drugs completely. Let the FDA focus on purity and rigorous testing and education, but take away its regulatory authority beyond that. Let pharmacies produce more drugs, and get the government in the business of producing drugs. Nothing will drive down drug prices faster than a public entity producing drugs in competition with private corporations. Give tax incentives to businesses for producing or researching drugs in the public interest. It's madness to think that somehow problems with overregulation and monopolies are going to be solved by increasing regulation and monopolies.
- shitgoose 10y ago
  "It's madness to think that somehow problems with overregulation and monopolies are going to be solved by increasing regulation and monopolies." this is exactly how most people think. i would rather say that it is madness to think that government will get into drug manufacturing (or manufacturing of anything for that matter) rather than quietly collect donations from interested parties in exchange for a signature.
- rayiner 10y ago
  > Nothing will drive down drug prices faster than a public entity producing drugs in competition with private corporations. State supported entities competing with private ones is now "free market?"
BurningFrog 10y ago
> why is it better for American people to persevere with a system where you pay 10, 100 times the fair price? The ability to charge far more for a drug than pure manufacturing cost is what makes it possible to spend billions and decades researching and developing it. That burden is mainly borne by US consumers, while the rest of the world mostly free-rides. More meat: http://slatestarcodex.com/2016/09/07/reverse-voxsplaining-brand-name-drugs/ http://slatestarcodex.com/2016/09/07/reverse-voxsplaining-br...
- aantix 10y ago
  Not sure why this doesn't get voted up more... The money has to come from somewhere. If 90% of the countries are basically just squeezing the drug company, then they have to raise prices where they can. The U.S. subsidizes the rest of the world.
- ferentchak 10y ago
  I always thought a simple solution to this would be that you cannot sell your drugs in the US for any higher than the lowest negotiated price the drug is sold for to the other rich western countries. For example if Drug A is negotiated to be for sale to the socialized medicine systems in Canada and France for $30 it cannot be sold for more than that here. This allows the company to set whatever price they think is reasonable but without the US subsitizing their costs. It also allows the companies to sell their drugs at low prices to developing economies so that the people living there can still have access to lifesaving treatments.
pandaman 10y ago
If people could not bargain healthcare prices when sick then they could bargain food prices even less when hungry, yet somehow we managed to have more or less free market for food. Let's not even go there. Let's look at a less regulated medical field of dentistry. Dentistry is relatively cheap and available because there is, while still heavily regulated, a market. I.e. you can call a doctor's office and get a quote for whatever procedures you want. Don't tell me that someone with acute toothache is in a superior bargaining position than someone with, say, elevated blood pressure. So the market works pretty well when you don't over regulate it. I somehow doubt that bringing even more regulation in form of single payer will suddenly fix anything.
- subhobroto 10y ago
  As you note, groceries are one of the most cut throat industries in the continental U.S. We import food from all other parts of the world and not end up paying through the nose for them. My belief is price transparency is party the reason for this, and we are utterly lacking that i nthis part of the world. A few people have told me that they would actively misrepresent their network status so as to get estimates from a provider before going aahead with a procedure: https://www.quora.com/Is-it-easier-for-an-uninsured-American-to-know-the-costs-of-a-medical-service-before-going-through-with-it https://www.quora.com/Is-it-easier-for-an-uninsured-American...

rm_-rf_slash 10y ago

Most Americans believe in a single-payer system. However, even if the Democrats made it a solid goal, the Republicans would essentially convey the message: "Sure, you can vote for the Democrats if you want, but be prepared for them to take all of your guns, force you to pay welfare for Syrian immigrants, and use your taxes to pay for abortions." Enough people would consider those things - even if they have an iota of truth - more important than universal health care, so they vote against the politicians who support it. This assumes republicans do not adopt a single payer system in their party platform. I think that assumption is plausible.

snowwrestler 10y ago
The argument against government single-payer is to imagine the politicians you dislike the most in charge of your health care. Would Democrats still favor single-payer if they knew that Republicans would get to make all the policy decisions about what is covered?
- Nursie 10y ago
  Yet other countries seem to make it work quite well and keep it a-political. No party decides these things.
  - snowwrestler 10y ago
    Some other countries make it work. Other other countries have health care systems that are way worse than the U.S. So: it's good to know that things are different in other countries, but it doesn't actually address the point I was trying to make. Of course single-payer works if we imagine that things in the U.S. are different from the way they actually are. Lots of things work that way.
    - Nursie 10y ago
      I'm not aware of any countries where that specific aspect, choosing which drugs are available, has become politicised and toxic. I agree that the two-party adversarial politics in the US is poison though, and causes a whole lot of "this is why we can't have nice things" moments.
    - otterley 10y ago
      > Of course single-payer works if we imagine that things in the U.S. are different from the way they actually are That's a fantastic argument for changing the way things are in the U.S. It happens one vote at a time.
- lintiness 10y ago
  more along the lines of: the government that can't seem to make anything cheap ever and that is mostly lying and full of shit all the time wants control of my WHAT?
  - ZeroGravitas 10y ago
    This is just a variant on "get your government hands off my Medicare". The healthcare "market" in the USA is deeply, pervasively and often bizarrely regulated by the government. Don't think of it as free market versus government regulated, because that's simply not true.

splintercell 10y ago

> I very much like free market. But here, the final consumer is not in a position to bargain prices when getting sick, which is a pre-requisite for a free market to function. Single-payer system works way better in that very particular industry, because both parties can now effectively negotiate. I am sorry but you don't like Free market. That's like saying "I love Hillary Clinton and I am totally with her, but I think Trump would be a better President than Hillary in every way because he is not dying". My friend describes this as a 'Sales Pitch argument' where you claim to support your opponent's position, but you actually don't. "I am all for Gays to be able to freely marry, but we gotta make sure that the kids they adopt aren't going to abusive homes because statistics say that kids raised by gay and lesbian couples don't do so well". > the final consumer is not in a position to bargain prices when getting sick, which is a pre-requisite for a free market to function. I don't know from where does this kind of faulty thinking originates. Lemme show you why it is faulty: The final consumer of food is not in position to bargain prices when he is hungry, which is a pre-requisite for free market to function. Therefore a single payer food system works better than a private food system. The final consumer of a gun is not in a position to bargain prices when his home is invaded, which is a pre-requisite for a free market to function. Therefore a single payer gun system works better than private market for guns. The problem is, you're not suppose to look for food only when you get hungry, or buy a gun precisely when you're getting invaded, you're suppose to do these things BEFORE you actually need them. And just like food (which you need daily multiple times) you buy in chunk. The whole system of food acquisition works out perfectly fine. Your rest of the comment is more to the point, and the way things are in America are antithetical to a free market in healthcare and pharma industry.

snowwrestler 10y ago
I agree with this, and I'll add that the system we have now actively prevents me from trying to apply price sensitivity. I have a chronic illness that requires me to take medicine every day; some prescription, some not. For the prescription medicine I get a prescription from my doctor. It does not tell me the price of the drug, nor does it tell me whether there is a generic available, or another brand-name drug with similar effect. Even if I ask, the doctor typically has no idea how much the various drugs cost, and which are less expensive. They just say "your insurance will cover this." I take it to the pharmacy. None of the pharmacies advertise their prices for this drug, so I have no reason to choose one over another. I fill the prescription and go to checkout. The price will be different depending on which tier the drug is on at my insurance company, the copay for that drug, or whether I've yet satisfied my deductible. The only way to predict these things in advance is to read through dozens of pages of dense literature from my insurance provider. And by the way, I have no choice in insurance provider because my employer only offers one. For the non-prescription medicine, the price is clearly marked in every store, and generics are clearly identified and merchandised right alongside the brand name. I have great opportunity to choose where and what to buy. And, no surprise, these are way cheaper than the prescription drugs. Keep in mind that my need for, and usage of, these drugs is exactly the same. But the price is radically different depending on whether they come to through the clarity of the market or the opacity of the current health insurance system.

replicatorblog 10y ago

The problem with the "can't negotiate" argument is that insurers have every incentive to negotiate on behalf of the patients they cover. And they have scale—United Healthcare covers more lives than the NHS. I worked at a startup that dealt with international reimbursement and we accepted less in France because it was just how it was done. We got paid much more in Germany and the UK. In the US we got paid a lot from some people and sold a very similar product to Walmart for 1/5th the cost. This was a small startup, not a global pharma company, though we worked with a few and saw similar patterns at play. History, as much as politics and economics, shapes the industry in profound ways.

e40 10y ago
The problem with the "can't negotiate" argument is that insurers have every incentive to negotiate on behalf of the patients they cover. And they have scale—United Healthcare covers more lives than the NHS. You would think, but they don't. That's the problem. Why? I don't know. Car insurance is a similar thing. My SO barely tapped the car in front of her at a stop light. No damage, even though the woman flew out of the car claiming her car was damaged (we have pics of no damage) and that her children were injured (two boys in the back seat without seat belts or car seats). My SO asked the boys if they were OK and they laughed and said "yes." So, a month or so later I get a call from the insurance company they've settled for medical bills of > $10k and damage to the car for ~$4k. I was livid and told them I wanted them to fight this fraud. Nope, they wouldn't do it. I begged the agent for 20 minutes. It's cheaper to settle. It would clearly be in the best interest of the insurance company to crack down on fraud, but they feel it's "cheaper" to settle and move on. I think the same mindset exists in the medical insurance industry.
- supergeek133 10y ago
  Same thing happened to me with auto insurance. State trooper shows up, asks everyone if they are OK, doesn't take a report because no damage. A year later my insurance settles with the guy for $4k, and my insurance premium almost doubles. Medical insurance is the same because the insurer, the drug company, and the doctor ALL benefit from increased prices.

astazangasta 10y ago

Drugs are often covered by patent monopolies and do not operate in a free market.

throwaway7767 10y ago
I can't understand why this is downvoted. A product that can only be manufactured by one company due to patents does not have a free market. That's not a value judgement of the patent system, it's just stating the obvious. A patent is a legally enforced monopoly, so of course there will be no competition while the patent is in force.

refurb 10y ago

Example: GSK is selling Advair Diskus for $300 in the US, and the same Seretide Diskus for 30 euros in France. Because on one side, they negotiate, and on the other, the enact laws to prevent negotiations (see Medicaid). As others have mentioned, there can be a big difference between the list price and the actual price the insurer pays. The asthma market is highly contracted with big rebates going to payers. Second, Medicaid does negotiate. First off, Medicaid get 23.1% off of every drug, just to start with. Then they can negotiate supplemental rebates if there is a lot of competition in a therapeutic area. When you add it all up, Medicaid pays some of the lowest costs for drugs of any payer.

coldcode 10y ago
Medicare is the problem, Medicaid is allowed to negotiate.
- refurb 10y ago
  Medicare Part D (prescription drugs) is entirely run by commercial payers who are allowed to negotiate (and do). Only Part B is limited from negotiating price, but discounts do happen in competitive markets and CMS captures those savings.
bisRepetita 10y ago
So basically, with a high deductible plan, I am getting screwed by my insurance company, because I do pay $300 for Advair out of pocket, instead of the negotiated price.
- refurb 10y ago
  Correct! You are typically responsible for the list price, not the net price the payer pays. So, you pay $300 for the drug (list price). The insurance company uses that $300 to pay the drug company, which in turn, rebates $150 back to the payer. Pure profit! If you are just responsible for the co-pay it works better. You pay $30, the payer pays $270 and the manufacturer rebates $150. Overall, the drug costs $150, $30 coming from you and $120 (net) coming from the payer.

jmde 10y ago

The problem is that it is not actually a free market. The government grants monopolies to prescribers, restricting access that way, and to drug manufacturers, through the FDA, directly or indirectly (it's crazy to me that the government grants these monopolies and then complains when businesses take advantage of them financially). Then you have the insurers, who are not actually the beneficiaries of the product and who are therefore not in a position to fully judge the benefit:cost ratios of the products. To me, the problem is lack of competition. The government should remove or sharply curtail licensing laws, or expand them to other professions substantially, and eliminate or loosen drug schedules (the new kratom fiasco is just one example of many spanning decades of how inept the government is at regulating substances). Basically, decriminalize and deregulate drugs completely. Let the FDA focus on purity and rigorous testing and education, but take away its regulatory authority beyond that. Let pharmacies produce more drugs, and get the government in the business of producing drugs. Nothing will drive down drug prices faster than a public entity producing drugs in competition with private corporations. Give tax incentives to businesses for producing or researching drugs in the public interest. It's madness to think that somehow problems with overregulation and monopolies are going to be solved by increasing regulation and monopolies.

shitgoose 10y ago
"It's madness to think that somehow problems with overregulation and monopolies are going to be solved by increasing regulation and monopolies." this is exactly how most people think. i would rather say that it is madness to think that government will get into drug manufacturing (or manufacturing of anything for that matter) rather than quietly collect donations from interested parties in exchange for a signature.
rayiner 10y ago
> Nothing will drive down drug prices faster than a public entity producing drugs in competition with private corporations. State supported entities competing with private ones is now "free market?"

BurningFrog 10y ago

> why is it better for American people to persevere with a system where you pay 10, 100 times the fair price? The ability to charge far more for a drug than pure manufacturing cost is what makes it possible to spend billions and decades researching and developing it. That burden is mainly borne by US consumers, while the rest of the world mostly free-rides. More meat: http://slatestarcodex.com/2016/09/07/reverse-voxsplaining-brand-name-drugs/ http://slatestarcodex.com/2016/09/07/reverse-voxsplaining-br...

aantix 10y ago
Not sure why this doesn't get voted up more... The money has to come from somewhere. If 90% of the countries are basically just squeezing the drug company, then they have to raise prices where they can. The U.S. subsidizes the rest of the world.
ferentchak 10y ago
I always thought a simple solution to this would be that you cannot sell your drugs in the US for any higher than the lowest negotiated price the drug is sold for to the other rich western countries. For example if Drug A is negotiated to be for sale to the socialized medicine systems in Canada and France for $30 it cannot be sold for more than that here. This allows the company to set whatever price they think is reasonable but without the US subsitizing their costs. It also allows the companies to sell their drugs at low prices to developing economies so that the people living there can still have access to lifesaving treatments.

pandaman 10y ago

If people could not bargain healthcare prices when sick then they could bargain food prices even less when hungry, yet somehow we managed to have more or less free market for food. Let's not even go there. Let's look at a less regulated medical field of dentistry. Dentistry is relatively cheap and available because there is, while still heavily regulated, a market. I.e. you can call a doctor's office and get a quote for whatever procedures you want. Don't tell me that someone with acute toothache is in a superior bargaining position than someone with, say, elevated blood pressure. So the market works pretty well when you don't over regulate it. I somehow doubt that bringing even more regulation in form of single payer will suddenly fix anything.

subhobroto 10y ago
As you note, groceries are one of the most cut throat industries in the continental U.S. We import food from all other parts of the world and not end up paying through the nose for them. My belief is price transparency is party the reason for this, and we are utterly lacking that i nthis part of the world. A few people have told me that they would actively misrepresent their network status so as to get estimates from a provider before going aahead with a procedure: https://www.quora.com/Is-it-easier-for-an-uninsured-American-to-know-the-costs-of-a-medical-service-before-going-through-with-it https://www.quora.com/Is-it-easier-for-an-uninsured-American...