Healthcare delivery system

2970 words (12 pages) Essay

1st Jan 1970 Health Reference this

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Executive summary

According to CFR website (2010), 16% of US budget went to healthcare in 2008 and it is expected that the healthcare budget will have risen up 25% by the year 2025. The health insurance supported by the employer-funded coverage. It was estimated that 29% of private employees in the US in 2006 did not have employer sponsored health plan which is also on the decline among low income workers. Due to high health insurance coverage, small businesses are unlikely to provide health insurance coverage as a benefit. The most expensive benefit in the U.S. is the healthcare at 12 %. Doing business in the U.S is very expensive just because of high costs in the healthcare. Due to all these factors, the senate and the house came up with a legislation that is to reform the healthcare and make it more affordable to everybody. This paper makes a summary of the legislation and its implications (CFR website, 2010).

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Healthcare Delivery Systems

Introduction

The current U.S. healthcare plan is not the best requiring more health care reforms. The country’s annual expenditure on healthcare is close to $2 trillions. U.S and Mexico and turkey are the only OECD counties without a universal healthcare. The pending legislation passé by the senate and the house is aimed at improving healthcare accessibility and cost. This includes upgrading the government- run health Medicare and Medicaid. The current system covers only a small fraction of the population with a good fraction unable to afford it (committee of energy and commerce website 2009). With the recession, much of the healthcare burden is borne by families and small businesses. With this, the state came up with the legislation to regulate the healthcare. The bill has not yet been passed but it has drawn lots of mixed reactions. This paper analyzes the four major components of the bill, who the bill will affect, the impact of the legislation to the public and the economy at large and the implementation process (committee of energy and commerce website, 2009).

The legislation

The US healthcare legislation has four major components namely the finance, the insurance, quality, and delivery components. All the four components make up the whole reform in the health care. The healthcare reform is not complete without reforms in the insurance sector. Therefore, insurance reforms are also included in the legislation. Let’s have the look at all of them one by one. With the new legislation, there will be increased competition among insurance firms due to the inclusion of public health insurance option and the creation of the health insurance exchange. This will increase transparency and efficiency as insurance will be more affordable (committee of energy and commerce website, 2009).

Low income earners (below 150% of the federal poverty level) will get an improved Medicaid program hence improving the Medicaid program.  This program will pick up immediately but financed by the state (bearing in mind the poor state of state economies) until 2015 after which it will be financed by the states.

Everybody including the disabled and senior citizens will benefit from this system because cost sharing for preventive medicine is eliminated, improved low income subsidy, increased primary care providers and other improvement in the healthcare program. All this will improve Medicare.

Finance

This component of the legislation involves source of funds for the system. It emphasizes on mutual responsibility for every body including employers, individuals and the government to ensure better healthcare for everybody. The current healthcare system is not affordable by all. The aim of this legislation is to ensure that all American citizens can not only afford but access the healthcare. The initial source of funds is from the state. To do so, the bill proposes the following:

Credits: Low and moderate income families will have credits. These will be higher for those who are just above income eligibility levels and they will decline with income increase. Therefore, the higher your income the lower will be the premiums and cost sharing support. Through this new legislation, there will be more access to healthcare due to affordable credits and low insurance premiums hence reduced cost-sharing. Also, there will be a cut on out of pocket spending.

Individuals: they must obtain and maintain health insurance coverage otherwise they will be liable for a fine of up to 2.5 % of adjusted gross income (Committee of energy and commerce website, 2009).

Employers: they have two options of either choosing to provide employee health insurance cover or contributing funds on their behalf. Contributions will be based on a percentage of the amount on the payroll. Those who choose to cover their employees will have to provide minimum benefit and contribution requirement just as specified in the proposal.

Small businesses: businesses with small payrolls less than $500,000 will be exempt from covering the employee. Those businesses that exceed the above will have to provide insurance cover as per the specifications in the proposal (Committee of energy and commerce website, 2009).

Government responsibility: the federal government will have to ensure that every U.S citizen can afford a quality healthcare coverage by implementing affordable credits, reforms in the insurance sector, improving the Medicare and Medicaid as well as protecting consumers (Committee of energy and commerce website 2009).

Insurance

The bill proposes several reforms to the insurance sector. These reforms are vital to the implementation of the health reforms. The proposed insurance reforms include:

a) Immediate reforms: these are the reforms that are to be implemented immediately the bill comes into action. They include formation of a national insurance program that is cheap and affordable coverage to everybody including low income earners. according to the committee of energy and commerce website (2009), required insurance include coverage of young adults as per their parent’s policies up to the age of 26 years, implementation of administrative simplification and creating new grant federal incentives (committee of energy and commerce website, 2009).

b) Insurance exchange and Health: this is to start in 2013. It will enable proper functioning of marketplace for individuals and small businesses employers to insurers. With the state insurance program in place, it will be possible to enforce consumer protection, insurance reforms and administer affordable credits to assist low and middle income earners to purchase insurance (committee of energy and commerce website, 2009).

c) Public insurance program: it will be equal to other insurance players in the market as it will be subjected to the same market reforms. It will be financed by the premiums thus self-sustaining. The initial start up fund will be provided but it should be self sustaining in the long run obtaining its funding from the premiums (committee of energy and commerce website, 2009).

d) Guaranteed insurance coverage and reforms: insurance companies will no longer discriminate who to cover. Also there will be no exclusion on coverage of treatments for pre-existing diseases. Through setting up of annual limits on benefits and prohibiting lifetime, the bill will protect consumers.

e) There will be no more antitrust exemption for the health insurers and insurers for medical malpractices. This because the bill will increase competition in the insurance market. And remove their capability to fix prices and creation of monopolies (committee of energy and commerce website, 2009).

Quality

The new legislation provides the following as far as the quality of health care is concerned. The state intends to do a lot of investments in various departments to ensure delivery of high quality and comprehensive healthcare. These are:

Ø Construction of new community health centers. This will increase the number of patients served.

Ø Prohibiting cost-sharing for preventive essential services, Medicare and Medicaid

Ø Introducing new community based programs that will ensure community level delivery of prevention and wellness services.

Ø Increased funding of research on clinical and community preventive healthcare services. This will aid in knowing the most effective service (committee of energy and commerce website, 2009).

Delivery

The legislation proposes a smooth delivery of healthcare through increased investment in new public health-infrastructure. This is meant to improve departments of public health. The proposed healthcare bill will ensure expanded healthcare workforce through:

Ø Increased funding to meet National Health Service corporation requirements.

Ø Diversification of the workforce through diversity programs. This will ensure efficiency of the health workforce.

Ø Expanded scholarship and loan repayment programs to all those individuals wanted in the health profession.

Ø Increasing physicians in the primary health care through training and redistributing them throughout the country (committee of energy and commerce website, 2009).

The delivery of the proposed healthcare also includes insurance cover for every body and the implementation of the whole legislation. The federal government is to ensure that every detail of the legislation is implemented. This will have to include ensuring that the coverage is universal and affordable even to low income people and small businesses. Therefore, insurance reforms are inevitable. The quality of the healthcare must also be met through increased investment in healthcare workforce and infrastructure.  Efficient reform of entire healthcare, the delivery of all the four components of the legislation must be done (committee of energy and commerce website, 2009).

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Legislation summary

This pending legislation is about the comprehensive health reforms that the health care requires. It is about provision of a good healthcare system that is affordable by everybody and not only a few.  Through this healthcare system, insurance providers will no longer provide monopoly but equal chance for all insurance providers in the market. As compared to the present system, better services will be provide since legislation proposes funding in all fields of the health care like research in preventive medicine, scholarships and loans for training in any healthcare related vacancies, construction of better  and more health infrastructure, etc. all these will provide better quality health services to the public. More so, many people will be able to be served.

Why need the legislation

The healthcare legislation is very vital to the average man in the U.S. and to the state at large. According to, the legislation will avail the following benefits:

Ø The proposed legislation will end the frequent discrimination by insurance companies. They will no longer deny coverage to pre-existing conditions like cancer, diabetes, heart disease or drop coverage those who get sick.

Ø Coverage will be more affordable to small businesses and families because premiums will be lower hence no more out-of-pocket spending. There will be no more co pays for preventive care. Small business will not pay more premiums based on employees’ health status as they will be covered through tax credits.

Ø There will be no monopolies since competition will grow with more insurance firms in competition.

Ø According to the CFR website (2009), it is estimated that the legislation will cover 96% of Americans significantly reducing the cost of provision of uncompensated care for 46millions of Americans. This will translate into low cost, increased savings hence investment.

Ø Through the coverage of the 96% of the American population with quality healthcare, the state will reduce the budget deficit.

Ø Through the elimination of out of pocket spending form the preventive services, the wellness and prevention will improve.

Ø Since the bill ensures that doctors and patients (and not insurance firms) make healthcare decisions, more family doctors will join the workforce. This will guarantee access to healthcare services.

Ø The proposed legislation will cut down on healthcare fraud, abuse and waste.

Ø In the long run the healthcare costs will be very low, since the bill prevents hospital readmissions and encourages doctors working together to enhance and individual’s health (CFR website, 2009)

Implementation of the healthcare legislation

The proposed legislation is very comprehensive. Therefore, its implementation will require serious dedication from both the federal and states governments. The federal government is to ensure that every U.S citizen has a healthcare insurance coverage. It is also to implement the proposed insurance reforms. On the other hand, the states will have to analyze the importance of the proposals to low income families and insurance companies. The bill calls on states design a Medicaid expansion and develop high risk insurance pools, despite delegating some authority to federal government. In addition to that, the state is required to decide major decisions on health reforms including establishing a health insurance exchange and determining the participating insurers (California health line website, 2009).

In this regard, states will have to employ more administrators in order to deliver on their new responsibility. According to California health line website (2010), much responsibility to implement the new law lies with the federal government. Just as experts say, this model allows states to learn from each other’s implementation experiences. Care should however be taken because some states could lag behind in the implementation process lowering the expected health standards (California health line website, 2009).

Impact of the legislation

The proposed legislation will have major impacts on the major systems of the economy as far as health care is concerned. The insurance sector will be streamlined opening up for other competitors and eliminating monopolies hence it will realize increased competition. Employers and individuals will also have top deviate from their normal daily routine. Employers will have no choice but to either provide employee health insurance cover or pay a certain amount of money as per the payroll. On the other hand, the individual will have to take and maintain a health insurance cover. In the end, low income individuals and small businesses will be in a position to access quality healthcare at low cost (CFR website, 2010).

The long term effect of implementing the legislation to the economy is not well known, though according to CFR website (2010), experts cast doubt on whether the proposed low costs of the healthcare will reduce the federal deficit.

Conclusion

The pending healthcare legislation is intended to reform the entire U.S healthcare system by introducing the government funded Medicare and Medicaid. The reform also touches the insurance sector. The insurance sector will no longer have monopolies but will be streamlined comprising of all insurance providers in the market. The funding of the healthcare cover will be mutually provided by all the parties among them the state, the individual and the employer, by the introduction of the credit facility, the small income individual can afford it and be easily covered. Quality healthcare will be provided through increased healthcare facilities and healthcare personnel. These are increased through increased funding and training.

The proposed legislation will impact hard on the sectors like the insurance sector and the entire healthcare sector. Both sectors will undergo major reforms which will improve the efficiency and completion. It is expected that the proposed legislation will reduce the federal expenditure in the long run.

References

California health line website. (2009). “U.S. Healthcare Reforms Could Leave Implementation to States.” retrieved on February 12, 2010 from: http://www.californiahealthline.org/articles/2009/11/2/us-health-care-reform-could-leave-implementation-to-states.aspx

CFR website. (2010). “Health costs and U.S competitiveness.” Retrieved on February 13, from: http://www.cfr.org/publication/13325/healthcare_costs_and_us_competitiveness.html

Committee on energy and commerce website. (2010). “Affordable healthcare for America act.” retrieved on February 12, 2010 from:http://energycommerce.house.gov/index.php?option=com_content&view=article&id=1687&catid=156&Itemid=55

Msnbc website, (2010). “Senate Passes Historic Health Care Legislation.” retrieved on February 12, 2010 from: http://www.msnbc.msn.com/id/34584011/

Seekingalpha website. (2010). “ETF Ideas poised to Benefit from Pending Healthcare Reform.” Retrieved on February 12, 2010 from: http://seekingalpha.com/article/109665-etf-ideas-poised-to-benefit-from-pending-healthcare-reform

The free enterprise nation website. (2010). “Pending healthcare reform legislation.” Retrieved on February 13, from: http://www.thefreeenterprisenation.org/FENI/media/Docs-Position/FEN%20Position%20Paper%20on%20Health%20Care%20Reform.pdf

Executive summary

According to CFR website (2010), 16% of US budget went to healthcare in 2008 and it is expected that the healthcare budget will have risen up 25% by the year 2025. The health insurance supported by the employer-funded coverage. It was estimated that 29% of private employees in the US in 2006 did not have employer sponsored health plan which is also on the decline among low income workers. Due to high health insurance coverage, small businesses are unlikely to provide health insurance coverage as a benefit. The most expensive benefit in the U.S. is the healthcare at 12 %. Doing business in the U.S is very expensive just because of high costs in the healthcare. Due to all these factors, the senate and the house came up with a legislation that is to reform the healthcare and make it more affordable to everybody. This paper makes a summary of the legislation and its implications (CFR website, 2010).

Healthcare Delivery Systems

Introduction

The current U.S. healthcare plan is not the best requiring more health care reforms. The country’s annual expenditure on healthcare is close to $2 trillions. U.S and Mexico and turkey are the only OECD counties without a universal healthcare. The pending legislation passé by the senate and the house is aimed at improving healthcare accessibility and cost. This includes upgrading the government- run health Medicare and Medicaid. The current system covers only a small fraction of the population with a good fraction unable to afford it (committee of energy and commerce website 2009). With the recession, much of the healthcare burden is borne by families and small businesses. With this, the state came up with the legislation to regulate the healthcare. The bill has not yet been passed but it has drawn lots of mixed reactions. This paper analyzes the four major components of the bill, who the bill will affect, the impact of the legislation to the public and the economy at large and the implementation process (committee of energy and commerce website, 2009).

The legislation

The US healthcare legislation has four major components namely the finance, the insurance, quality, and delivery components. All the four components make up the whole reform in the health care. The healthcare reform is not complete without reforms in the insurance sector. Therefore, insurance reforms are also included in the legislation. Let’s have the look at all of them one by one. With the new legislation, there will be increased competition among insurance firms due to the inclusion of public health insurance option and the creation of the health insurance exchange. This will increase transparency and efficiency as insurance will be more affordable (committee of energy and commerce website, 2009).

Low income earners (below 150% of the federal poverty level) will get an improved Medicaid program hence improving the Medicaid program.  This program will pick up immediately but financed by the state (bearing in mind the poor state of state economies) until 2015 after which it will be financed by the states.

Everybody including the disabled and senior citizens will benefit from this system because cost sharing for preventive medicine is eliminated, improved low income subsidy, increased primary care providers and other improvement in the healthcare program. All this will improve Medicare.

Finance

This component of the legislation involves source of funds for the system. It emphasizes on mutual responsibility for every body including employers, individuals and the government to ensure better healthcare for everybody. The current healthcare system is not affordable by all. The aim of this legislation is to ensure that all American citizens can not only afford but access the healthcare. The initial source of funds is from the state. To do so, the bill proposes the following:

Credits: Low and moderate income families will have credits. These will be higher for those who are just above income eligibility levels and they will decline with income increase. Therefore, the higher your income the lower will be the premiums and cost sharing support. Through this new legislation, there will be more access to healthcare due to affordable credits and low insurance premiums hence reduced cost-sharing. Also, there will be a cut on out of pocket spending.

Individuals: they must obtain and maintain health insurance coverage otherwise they will be liable for a fine of up to 2.5 % of adjusted gross income (Committee of energy and commerce website, 2009).

Employers: they have two options of either choosing to provide employee health insurance cover or contributing funds on their behalf. Contributions will be based on a percentage of the amount on the payroll. Those who choose to cover their employees will have to provide minimum benefit and contribution requirement just as specified in the proposal.

Small businesses: businesses with small payrolls less than $500,000 will be exempt from covering the employee. Those businesses that exceed the above will have to provide insurance cover as per the specifications in the proposal (Committee of energy and commerce website, 2009).

Government responsibility: the federal government will have to ensure that every U.S citizen can afford a quality healthcare coverage by implementing affordable credits, reforms in the insurance sector, improving the Medicare and Medicaid as well as protecting consumers (Committee of energy and commerce website 2009).

Insurance

The bill proposes several reforms to the insurance sector. These reforms are vital to the implementation of the health reforms. The proposed insurance reforms include:

a) Immediate reforms: these are the reforms that are to be implemented immediately the bill comes into action. They include formation of a national insurance program that is cheap and affordable coverage to everybody including low income earners. according to the committee of energy and commerce website (2009), required insurance include coverage of young adults as per their parent’s policies up to the age of 26 years, implementation of administrative simplification and creating new grant federal incentives (committee of energy and commerce website, 2009).

b) Insurance exchange and Health: this is to start in 2013. It will enable proper functioning of marketplace for individuals and small businesses employers to insurers. With the state insurance program in place, it will be possible to enforce consumer protection, insurance reforms and administer affordable credits to assist low and middle income earners to purchase insurance (committee of energy and commerce website, 2009).

c) Public insurance program: it will be equal to other insurance players in the market as it will be subjected to the same market reforms. It will be financed by the premiums thus self-sustaining. The initial start up fund will be provided but it should be self sustaining in the long run obtaining its funding from the premiums (committee of energy and commerce website, 2009).

d) Guaranteed insurance coverage and reforms: insurance companies will no longer discriminate who to cover. Also there will be no exclusion on coverage of treatments for pre-existing diseases. Through setting up of annual limits on benefits and prohibiting lifetime, the bill will protect consumers.

e) There will be no more antitrust exemption for the health insurers and insurers for medical malpractices. This because the bill will increase competition in the insurance market. And remove their capability to fix prices and creation of monopolies (committee of energy and commerce website, 2009).

Quality

The new legislation provides the following as far as the quality of health care is concerned. The state intends to do a lot of investments in various departments to ensure delivery of high quality and comprehensive healthcare. These are:

Ø Construction of new community health centers. This will increase the number of patients served.

Ø Prohibiting cost-sharing for preventive essential services, Medicare and Medicaid

Ø Introducing new community based programs that will ensure community level delivery of prevention and wellness services.

Ø Increased funding of research on clinical and community preventive healthcare services. This will aid in knowing the most effective service (committee of energy and commerce website, 2009).

Delivery

The legislation proposes a smooth delivery of healthcare through increased investment in new public health-infrastructure. This is meant to improve departments of public health. The proposed healthcare bill will ensure expanded healthcare workforce through:

Ø Increased funding to meet National Health Service corporation requirements.

Ø Diversification of the workforce through diversity programs. This will ensure efficiency of the health workforce.

Ø Expanded scholarship and loan repayment programs to all those individuals wanted in the health profession.

Ø Increasing physicians in the primary health care through training and redistributing them throughout the country (committee of energy and commerce website, 2009).

The delivery of the proposed healthcare also includes insurance cover for every body and the implementation of the whole legislation. The federal government is to ensure that every detail of the legislation is implemented. This will have to include ensuring that the coverage is universal and affordable even to low income people and small businesses. Therefore, insurance reforms are inevitable. The quality of the healthcare must also be met through increased investment in healthcare workforce and infrastructure.  Efficient reform of entire healthcare, the delivery of all the four components of the legislation must be done (committee of energy and commerce website, 2009).

Legislation summary

This pending legislation is about the comprehensive health reforms that the health care requires. It is about provision of a good healthcare system that is affordable by everybody and not only a few.  Through this healthcare system, insurance providers will no longer provide monopoly but equal chance for all insurance providers in the market. As compared to the present system, better services will be provide since legislation proposes funding in all fields of the health care like research in preventive medicine, scholarships and loans for training in any healthcare related vacancies, construction of better  and more health infrastructure, etc. all these will provide better quality health services to the public. More so, many people will be able to be served.

Why need the legislation

The healthcare legislation is very vital to the average man in the U.S. and to the state at large. According to, the legislation will avail the following benefits:

Ø The proposed legislation will end the frequent discrimination by insurance companies. They will no longer deny coverage to pre-existing conditions like cancer, diabetes, heart disease or drop coverage those who get sick.

Ø Coverage will be more affordable to small businesses and families because premiums will be lower hence no more out-of-pocket spending. There will be no more co pays for preventive care. Small business will not pay more premiums based on employees’ health status as they will be covered through tax credits.

Ø There will be no monopolies since competition will grow with more insurance firms in competition.

Ø According to the CFR website (2009), it is estimated that the legislation will cover 96% of Americans significantly reducing the cost of provision of uncompensated care for 46millions of Americans. This will translate into low cost, increased savings hence investment.

Ø Through the coverage of the 96% of the American population with quality healthcare, the state will reduce the budget deficit.

Ø Through the elimination of out of pocket spending form the preventive services, the wellness and prevention will improve.

Ø Since the bill ensures that doctors and patients (and not insurance firms) make healthcare decisions, more family doctors will join the workforce. This will guarantee access to healthcare services.

Ø The proposed legislation will cut down on healthcare fraud, abuse and waste.

Ø In the long run the healthcare costs will be very low, since the bill prevents hospital readmissions and encourages doctors working together to enhance and individual’s health (CFR website, 2009)

Implementation of the healthcare legislation

The proposed legislation is very comprehensive. Therefore, its implementation will require serious dedication from both the federal and states governments. The federal government is to ensure that every U.S citizen has a healthcare insurance coverage. It is also to implement the proposed insurance reforms. On the other hand, the states will have to analyze the importance of the proposals to low income families and insurance companies. The bill calls on states design a Medicaid expansion and develop high risk insurance pools, despite delegating some authority to federal government. In addition to that, the state is required to decide major decisions on health reforms including establishing a health insurance exchange and determining the participating insurers (California health line website, 2009).

In this regard, states will have to employ more administrators in order to deliver on their new responsibility. According to California health line website (2010), much responsibility to implement the new law lies with the federal government. Just as experts say, this model allows states to learn from each other’s implementation experiences. Care should however be taken because some states could lag behind in the implementation process lowering the expected health standards (California health line website, 2009).

Impact of the legislation

The proposed legislation will have major impacts on the major systems of the economy as far as health care is concerned. The insurance sector will be streamlined opening up for other competitors and eliminating monopolies hence it will realize increased competition. Employers and individuals will also have top deviate from their normal daily routine. Employers will have no choice but to either provide employee health insurance cover or pay a certain amount of money as per the payroll. On the other hand, the individual will have to take and maintain a health insurance cover. In the end, low income individuals and small businesses will be in a position to access quality healthcare at low cost (CFR website, 2010).

The long term effect of implementing the legislation to the economy is not well known, though according to CFR website (2010), experts cast doubt on whether the proposed low costs of the healthcare will reduce the federal deficit.

Conclusion

The pending healthcare legislation is intended to reform the entire U.S healthcare system by introducing the government funded Medicare and Medicaid. The reform also touches the insurance sector. The insurance sector will no longer have monopolies but will be streamlined comprising of all insurance providers in the market. The funding of the healthcare cover will be mutually provided by all the parties among them the state, the individual and the employer, by the introduction of the credit facility, the small income individual can afford it and be easily covered. Quality healthcare will be provided through increased healthcare facilities and healthcare personnel. These are increased through increased funding and training.

The proposed legislation will impact hard on the sectors like the insurance sector and the entire healthcare sector. Both sectors will undergo major reforms which will improve the efficiency and completion. It is expected that the proposed legislation will reduce the federal expenditure in the long run.

References

California health line website. (2009). “U.S. Healthcare Reforms Could Leave Implementation to States.” retrieved on February 12, 2010 from: http://www.californiahealthline.org/articles/2009/11/2/us-health-care-reform-could-leave-implementation-to-states.aspx

CFR website. (2010). “Health costs and U.S competitiveness.” Retrieved on February 13, from: http://www.cfr.org/publication/13325/healthcare_costs_and_us_competitiveness.html

Committee on energy and commerce website. (2010). “Affordable healthcare for America act.” retrieved on February 12, 2010 from:http://energycommerce.house.gov/index.php?option=com_content&view=article&id=1687&catid=156&Itemid=55

Msnbc website, (2010). “Senate Passes Historic Health Care Legislation.” retrieved on February 12, 2010 from: http://www.msnbc.msn.com/id/34584011/

Seekingalpha website. (2010). “ETF Ideas poised to Benefit from Pending Healthcare Reform.” Retrieved on February 12, 2010 from: http://seekingalpha.com/article/109665-etf-ideas-poised-to-benefit-from-pending-healthcare-reform

The free enterprise nation website. (2010). “Pending healthcare reform legislation.” Retrieved on February 13, from: http://www.thefreeenterprisenation.org/FENI/media/Docs-Position/FEN%20Position%20Paper%20on%20Health%20Care%20Reform.pdf

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