Thursday, March 03, 2011

Health Care, Incentives, and Complexity

-- Posted by Neil H. Buchanan

Discussions of public policy issues are, of necessity, carried on in abstract and impersonal terms. Most economists, for example, have never experienced long-term unemployment; but they must somehow try to understand that problem, to devise ways to reduce it. Moreover, personal experiences can be idiosyncratic, rather than illustrative; and the person experiencing them can have emotional responses that might make him less objective than he ought to be.

Even so, personal experiences can also bring unseen problems into the light, and bring into focus problems that have been acknowledged but poorly understood. For example, calls to have members of Congress file their own taxes, or to have governors register their own cars with their states' DMVs, are based on the belief that there is nothing quite like lived experience to break through a person's apathy about others' plight.

Health care is one of those issues for which seeing how the other 95% live might well lead to changes in policymakers' and analysts' attitudes about what is acceptable. Set aside the question of whether we should have a universal single-payer national health plan, or a public option, or (at the other end of the spectrum) replace traditional Medicare with vouchers. Set aside also disagreements over the constitutionality of the 2010 health care law. Focus instead on the current system of health insurance in the United States.

As I tell my students in Law and Economics, no matter what one thinks about concepts of efficiency, rationality, market clearing, and all the rest, the one thing that is always worth studying is the incentive effects of various policies and practices. Some of my recent experiences have clarified for me some important issues in the health care debate, especially as they relate to incentives and people's likely responses to changes in those incentives.

I am fortunate enough to have employer-provided health insurance coverage. It is not by any means lavish, but I am given a menu of coverage options each year, with different premiums; and I have not yet been kicked out of an insurance plan for pre-existing conditions or any of the other horror stories that are all too common in our current chaotic system of health insurance. Every college and university at which I have taught has provided a similar package of choices, so this is something with which I have had ample opportunity to become familiar. (Being a Contracts professor also makes me unusually likely to pay attention to the details of such things.)

Five years ago, I experienced a scary episode while biking in Manhattan. I collapsed on the street and was rushed by ambulance to Roosevelt Hospital. As it turned out, I was fine, but they quite sensibly ran a series of tests and kept me in the hospital overnight. I was living in Manhattan at the time, and my employer had thousands of employees living in New York City. Even so, it turned out that my care was incorrectly coded as "out of network" (and thus vastly more expensive to me) -- a mistake that, once entered into the system, required Herculean efforts (and persistence) to correct. I soon embarked on an 18-month-long odyssey through the bureaucratic nightmare that is health coverage in the US.

The logic of the in-network/out-of-network distinction is not obvious, but the theory is that health insurers can negotiate lower costs with certain providers. If a patient chooses not to use those providers, then the theory is that the patient should pay more. Incentives, right?

A few years after the biking incident, I was visiting friends in snowy, icy Ithaca, New York. At one point, our car became stuck on the ice, and I walked on the ice to try to push the car. Without warning, I slipped and hit the back of my head on the ice. I have never felt such intense pain. After a few minutes, however, I gathered myself and told my friends that there was nothing seriously wrong. What was really going through my mind, however, was: "If I go to a hospital and nothing's wrong, how much money and time will this cost me, especially because I have to assume that all local providers (hundreds of miles from my home) are out of network?" Despite the risks of a possible concussion, and ignoring the entreaties of my friends, I toughed it out -- and went to sleep that night knowing that doing so could end my life. I won that bet.

Fast forward to December 13, 2010. By that point, I had been living in Ithaca for over a year. Standing in line at a coffee shop, I was overwhelmed by weakness and nearly lost consciousness. As I was spiraling downward, I kept thinking that I needed to avoid using medical services, because the hassle is just too great. Surely, I thought, I can tough this one out, too. Finally, however, I had no choice but to ask someone to call 911. The ambulance soon arrived, and I went to the ER. I was treated and released the same day.

The bills started arriving almost immediately. In the end, this event cost me about $1,200 out of pocket. I finally called my health insurer to find out why it had cost so much. I discovered that the annual deductible applies to everything, even emergency care, and that patients pay 20% of in-network expenses beyond the deductible, and 30% of out-of-network expenses. Even so, the agent was confused, because I had already reached my deductible limit, yet I was charged the full $750 deductible. After some investigation, he discovered that my plan actually had two annual deductibles, one for in-network and one for out-of-network. The ambulance service was out-of-network, so I paid the full deductible for that, plus 30%.

Back to incentives. First, why in the world is emergency care even subject to deductibles? If the idea behind deductibles is to discourage people from treating expensive things as cost-free, then surely that logic does not apply to a person who is choosing between calling an ambulance or possibly dying. It is possible, I suppose, that there are people who would happily call an ambulance for a minor issue. Can that really outweigh the disincentive for people like me, going forward (now that I know about this rule), to inadvisedly refuse to call an ambulance to save a thousand dollars? Moreover, even if one wants to discourage people from using emergency services, how is one to know about the in-network/out-of-network status of the ambulance that will arrive? Everything else during that incident turned out to be in-network, which is sensible, given that I lived there. The ambulance was not. I guess I was supposed to find out whether the ambulance was in-network and then send them away when I learned that they were not, to wait for a second ambulance.

The larger issue, however, is how incentives are supposed to work with something as complex as health insurance. The various details of the health care plans from which I could choose are available on-line, somewhere, but the page from which one makes choices lists only monthly premiums. With so many moving parts -- in-network deductibles, out-of-network deductibles, co-pays, coinsurance, exclusions, and so on -- how confident are we that people can process the information necessary to make rational choices, even if they were to click through to the details of the various plans? I only found out about many of these details after the fact, because (and only because) I was willing and able to take the time to wade through the paperwork and spend time on the help line -- talking with someone who admitted that he could not figure it out, either!

Over the last few years, my co-pays for doctor visits and medications (also subject to an annual deductible) have gone from $5, to $10, to $15, to $35. David Leonhardt, the economics columnist for The New York Times, wrote in an article yesterday that a system with no or low co-pays "leads to lots of medical treatments that don’t make people any healthier, and to huge costs." (I will have more to say about that column in a future post.) Maybe so (or maybe not), but a system with high co-pays and hidden costs encourages people to choose not to see doctors or take medications -- which also will not make people any healthier, and can lead to huge costs later. At least co-pays are a cost that people know up front. Still, however, it is not at all obvious that this is the best way to reduce over-treatment.

What is obvious is that health care costs are being shifted onto families, seemingly at an accelerating rate. I am still fortunate enough to have health insurance coverage (until, perhaps, I really need it), and I am also fortunate enough that the completely unknowable $1200 cost of this most recent episode was not financially debilitating. Harnessing the power of incentives, however, is not as simple as raising people's costs. Even for those who read the fine print of their health care plans (and the alternatives), the actual import of the various provisions often cannot be known in advance. The flipside of incentives, moreover, is perverse incentives. The current system seems to be running a surplus of those.


Prup (aka Jim Benton) said...

I wish you'd included two of the worst disincentives of the current Medicaid system that get totally ignored in the discussion.

The first is ignored by Republicans who claim "Oh, the poor have their own 'insurance.' All they need to do is go to the emergency room." Now ignoring certain facts, like the inevitable wait that can be as much as 24 hours of sitting, or the possibility that during that waiting time -- as my wife continually worries about -- you will be sitting in a room with a couple of dozen people, at least one of whom may have something communicable, so that you might 'lrsvr sicker than you arrived,' let's look just at the financial aspects.

Emergency rooms are not 'free.' You are charged for emergency room visits, in fact, you usually are charged more than for a doctor's office visit. The only difference is that they don't 'come after you for payment' -- or not often. And they can't refuse to treat you if you've 'stiffed' them the last two dozen visits.

And, if you plan on 'staying poor' that's not a problem. You don't have credit to be wrecked, you don't lose anything by tearing those bills up. Of course, if you DO get a job and straighten up your life, you'll have those defaults on your credit record, and you damn well better get them paid.

[My post was too long, breaking it into parts]

Prup (aka Jim Benton) said...

But there is a worse disincentive, one which no one realizes until it bites them. Let's say you have a 'poor period' and have to get assistance from Medicaid. Then you 'straighten out your life,' leave Medicaid, and join the 'world of work.' You do pretty well, and then the inevitable happens and you become a subject for probate.

Medicaid has the right -- which they do exercise to reclaim every cent they paid you during your lifetime 'off the top' of your estate.

Now I am someone whose health is not great. Up to now most of the problems have been 'mechanical ones' (arthritis, disc problems, a torn rotator cuff, s tear in my knee, an infected foot that -- without an immediate operation -- I would have lost) that weren't 'life threatening.' But they were expensive, and most of the procedures I've needed, including one of two operations are in my Medicaid record. (The foot operation was when I was uninsured. Fortunately the hospital made a number of mistakes including one which -- were it not for a 1 in a hundred chance -- would have given me a broken leg, so I settled on a 'you don't sue me, I won't sue you' basis.)

But now I have a new problem, that may be more serious -- waiting on an appointment, assuming I can find a urologist that takes my type of Medicaid. (Another point people forget is that the government only certifies that you are eligible. After that -- do I have to tell stories of being wrongly kicked off three of the last four renewals -- you are assigned to the 'medicaid dept.' of a regular insurance company which administers it in its own way, including what doctors you can go to, which medicines they will pay for, etc.)

Hopefully this will be 'nothing,' that my symptoms will have a simple cause. If not, it might require a lot of treatment. And I am not sure if, because I am on my wife's account -- she's legally disabled because of emotional problems, and even were I in physical shape to get a job and were able to find one at age 64, with my physical problems and with a lousy work history, I'm needed at home -- she too will be charged with my procedures as well as her considerable expenses.

Now if we remain poor, no problem, but there is at least a good chance she will inherit a reasonably large amount from a relative who has just turned 90 -- a very healthy 90, but 90. There is even a possible chance that I might get healthy enough to finally sell a detective story or two -- unlikley after 50 years of trying, but not impossible.

Afaik, they can't/won't reclai what they've paid us from money we received, but if we had heirs, they'd see nothing until Medicaid took back every cent we'd received.

What an incentive to get out of poverty!!!

And I wouldn't have even known about it, even being on Medicaid, if we hadn't had to consult a lawyer about my wife's disability. I could have spent years getting Medicaid, years off it doing well, and would have no idea that my estate would be subject to the 'grab back.'

I love both Broklyn and America, and don't have the resources to move if I wanted to. But I envy my Canadian correspondents -- and my recently deceased Canagian sister-in-law -- for their country's attitude towards the sick. (Ovarian cancer finally killed her, but the treatment she received, even though she was just a long-time resident and not a citizen, was as good or better as she could have gotten a hundred miles south, and helped her survive twice as long as her original prgnosis -- despite the Republican myths about Canadian medicine.)

J Pahnke said...

My congrats at having navigated successfully through the labyrinth of our health care "system." Can you imagine what it would have been like if you had had to navigate through the even more labyrinth-like system that will, when fully implemented, be Obamacare, or if the government itself who was providing you that care was the person on the other end of the line who couldn't "figure out" what coverage you were entitled to?(see obamacare chart here ).
Not to denigrate the pain in the ass, (and/or head?!) your experiences were, but you are indeed lucky to have the coverage you do, (as opposed to myself, who currently has NO coverage, nata, nill, zip). I will resist the urge to lapse into the soup de jour of modern politics that is class warfare and gripe or otherwise begrudge you of that fact.
Also, I will at this point resist the urge to provide a defense of current insurance practices or the rationale behind the largely free enterprise system that has given us the highest quality health care system in the world to which both Saudi Arabian sultans and Canadians stealing across the border for care unanimously attest, (which, arguably, we do pay a premium for, but as my mother used to say, you get what you pay for!) I more exhaustively look at such things on my own blog.

However, I do find merit to your argument about emergency care deductibles vis a vis incentives, (and to a lesser extent, "out of network differences" to your out-of-pocket costs).

Too bad that the "Affordable Health Act" that the Administration seems hellbent on enforcing in spite of its being found unconstitutional, (and regardless of the blatant contradiction belied by the Administration's "principled" stance on the DOMA), will be a zillion times MORE complicated.

Indeed, coming on the heels of the GAO report showing billions of dollars of duplication, waste and fraud in other services the government has got its paws into, its more than a truism to say that I think nearly ALL of the problems you cite could be better served by unleashing market forces to provide innovative solutions, (as the Republicans have tried to do for years).

Maybe when we defeat Obama in 2012 we'll get the chance to try some of them.

J Pahnke said...

Jim, If Canada's system is so great, how come they are trying to kill off a child whose parent's would like to simply insert a tracheotomy to allow their child to come home to die, or the fact Canada itself is experimenting with pay for service clinics, (or, as I have already noted, so many Canadians come here for our health care?

Oh, and here's the link to the Obamacare labyrinth which I forgot to include last time.

Cheerio. jp

Prup (aka Jim Benton) said...

I had neither expected as prompt a reply, nor as one filled with point-missing, inaccurate Republican Propaganda, misinformation and flat out lies as the contribution from the head of the A.C.L.P. -- which is not the same as the American Center for Law and Justice he hopes you will confuse it with. (His organization -- which seems to be a one-person affair, and which just might be a beautiful JonSwiftian put-on -- does nothing more than produce a pretentious blog commenting on legal decisions.)

He speaks about "American having the greatest system of medicine in the world." That's grown more and more dubious, but even if we grant him that, that is true only for the 'Saudi Arabian sultans' who can afford it. (Th myth of Canadians 'sneaking across the border' is repeated many times, but I'd like to see a few actual examples.)

He claims to have no insurance -- though if I had to guess, he's still eligible under his parents coverage, even before Obama care gave him an additional five years. If it is true, since I refuse to wish even fools ill, I hope he is not faced with trhe choice I would have had to make, had my foot operation occurred before my wife's breakdown.

We couldn't afford to put me on her coverage. so, had the foot problem occurred while we had income -- and had the hospitak not made the series of blunders it did -- I would have had to face the Jack Benny line in real life, only it wouldn't have been 'your money or your life' but 'your money or your foot.' The operation would have cost me approximately what our family income was for that year -- gross, not net. (And, btw, emergency rooms -- which is how I entered the hospital but with advance notice from my foot doctor -- don't do operations.)

Of course this is hardly surprising for someone one of whose citations is to a website for someone who was running a "Tea Party" attack on a South Carolina Republican Congressman for being too 'liberal/socialist' and who lists Liberal Fascism -- the single most laughable and discredited political analysis from a major publisher in years -- and Darwin's Black Box -- Michael Behe's 'classic' of Young Earth Creationism -- as among his favorite books.

But his specific stupidities can stand some refutation. No, sir, having dealt with governmental, private, and mixed agencies for much of my life in various ways, I have little doubt that the governmental ones are usually more efficient. But yes, they are frequently so budget-slashed that their employees are over-worked (the old Nordquist ploy "Cut the budget so they do a bad job, then eliminate them for doing a bad job") and make mistakes. The difference is that when a governmental agency makes a mistake, you have an immediate right to review, and can delay its enforcement until there is a fair hearing. Try that on your private industry tintype.

And I have watched (private) doctor's offices try and figure out 'what i was entitled to.' And they are both slower and less accurate than governmental agencies, which have the relevant charts close to hand, not in a library of different plan provisions.

Obamacare 'complexity'? Only to someone like Mulvaney, who uses the somewhat tacky and antiquated political trick of piling up books of regukations without bothering to open them. (And who would -- if he wanted to -- be able to create twice as high a pile by stacking private insurance regulations.)

I could go on, "Mr. President" Anreas could go away, or maybe he could just lose the pretentiousness and propaganda and actually try and contribute to the discussion.

J Pahnke said...

"@JP - I'd love to get it [censorship] to stop as your responses have been interesting and have added to the debate..." -Doug

Doug, from the comment thread at post "A shift in Washington's attitude towards home ownership"

“Thanks JP. It's been fun.” - Egarber

From “The Enforcement/Defense calculus in DOMA and beyond” thread.

Now I may not be near as "enlightened" as you are Jim, but I find such a thing as these posters have replied to me to be awfully strange for someone who doesn't "try and contribute to the discussion" as you sensationally claim.

Moreover, Mr. Benton's brash assertion that government does “everything more efficiently” is plainly not accurate. Apparently he has never heard about his “efficient” government's five hundred dollar toilet seats or, so it seems, even read Mr. Buchanan's post above, which itself contradicts his claim (or at least gives credence to the argument of the other side):

“For example, calls to have members of Congress file their own taxes, or to have governors register their own cars with their states' DMVs, are based on the belief that there is nothing quite like lived experience to break through a person's apathy about others' plight. Health care is one of those issues for which seeing how the other 95% live might well lead to changes in policymakers' and analysts' attitudes about what is acceptable.” Mr. Neil Buchanan, “Health Care, Incentives, and Complexity.”

Indeed, while Mr. Benton may have lots of experience in the health care system, he apparently has not visited his state DMV office in quite a while.

Similarly, his claim that:

“when a governmental agency makes a mistake, you have an immediate right to review, and can delay its enforcement until there is a fair hearing,” I find extremely specious vis a vis the context of an expanded role for government in health care, (i.e., Obamacare), for the simply fact that who's to make it if it doesn't? Indeed, from my post on this subject at the ACLP's website,

“If we make government, the current regulator over fair health practices into a health insurance provider or player itself, (as Obamacare ultimately does), who will regulate the regulators? Right now there are laws against health insurers denying care wrongly, and if necessary, the people's representatives can pass new ones if necessary, as the Democratic process allows...
However, if the government itself is the provider of your health care, if they have the first and final say establishing what care you should receive and the government itself denies your claim, who are you going to turn to then? Indeed, by making government itself a stakeholder in the outcome, rather than the government merely being an impartial referee which applies the same rules to all, the entire system is rigged from the getgo against you and turned on its head.
From Feb. blog post, “So what's really the problem with Obamacare?”- ACLP blog

Finally, I am actually heartened at the thought that if personal attack is the only way Benton and Co. can respond to my arguments then they must really be quite bankrupt idea-wise (and likely terrified of the headway I am making! :) Otherwise, why the need to demonize?

Moreover, and best of all, since I and the ACLP are just the fledgling "one-person affair" he alleges, it is gratifying to know from our web analytics today that by highlighting our organization and its blog he has single-handedly driven an increase in traffic to our site by more than 300%, (thank you Mr. Benton! :) Moreover, the fact he felt he had to resort to such tactics heartens me at the soundness of my arguments. Indeed, as another more wise than I once said, "if you must resort to personal attacks and smears to win the argument you've already lost it.”

Jp Andreas, President, ACLP

J Pahnke said...

NOTE TO FREE SPEECH LOVERS: Since, once again, my attempts to rebut Jim Benton's slanderous personal attacks on me in this thread a couple days ago are REPEATEDLY CENSORED, so please see PART ONE in my full reply to 'Prups' ad hominem, guilt by association garbage at our blog (And yes btw, I have repeatedly tried to post Part One BEFORE Part Two which seems to be 'sticking' but for some reason when I finally 'refreshed' expecting both posts to show the first had been removed, (even though it had showed up fine immediately after my first post). Of course, I have been assured no one is personally tinkering with my posts because that would be an egregious example of tyranny of the majority, (something I have learned on dorfonlaw is an important constitutional principle). Thanks for everyone's patience and for those who have take the time to comment on the ACLP site. "Quod licet Jovi, non licet bovi"!
jp, Pres. ACLP

J Pahnke said...

CORRECTION: I correct my last post and apologize to 'handbagsforall' for my apparently incorrect theorizing that he/she didn't even sound like a real user/poster. on Don't know how I missed it but he/she has legitimately posted in Mr. Buchanan's post "Some Health Care Progress is Better Than None." I however stand by my other comments and call for the user mixup and censorship issues to be figured out/resolved. jp

J Pahnke said...

Doug- "JP - The case in Canada you cite is an unfortunate one...."

A: Even if the U.S. Hospital had refused to accept the case, that doesn't change the terrible precedent and premise that life and death decisions should be forced upon a family in what, for all intensive purposes, amounts to rationing of care. (btw the inevitable result of OC also).

D: To say that Obamacare has been found unconstitutional is to ignore the many courts that found it constitutional and is quite misleading...

A: Again, you miss my point, which is the Administration's hypocrisy. On the one hand, they drop defense of the 14 year old DOMA after a decision by merely one Federal District Court, while simultaneously on the other they fail to heed the Order of two District Courts as pertains to Obamacare which have expressly pronounced its unconstitutionality in initial challenges. Moreover, only three fed courts have ruled OC is constitutional. As such, it is mere spin to characterize this close 3-2 split in favor of constitutionality as “many courts have found it unconstitutional” and my statements as “misleading.”

D: Your point about fraud and waste in government is a non-sequitur. Yes, there is fraud and waste in government but there is also fraud and waste in private insurance... [it] doesn't mean that government should be abolished...

A: Who said anything about abolishing government? Yes, there most certainly is waste and fraud in both government and private companies. My point goes to degree, and the most effective means of addressing this state of affairs. Even if true, you only underscore my key points, 1) In light of the extensive corruption and inefficiencies in all things governmental, yours is not an argument for giving the government more control over what you already admit is a wasteful system but less, and, 2) If the government both regulates as well as establishes the rules for/provides this “one size fits all” health system, it will inevitably have no incentive to “get it right” when making life and death decisions effecting people who will be, in all honesty, just another “number.” You thus have ignored the penultimate question I have raised, (i.e., who will regulate the regulators?) At least insurance companies have law suits and stockholders to fear, (after all, companies which are repeatedly sued or fined by regulators go out of business). Government won't even have that incentive under theories of “sovereign immunity.” (Thus, common sense dictates against allowing the government to play the role of the Fox guarding the chicken coop!) As I have already noted, any reforms necessary can more effectively be instituted one at a time to better regulate the insurance companies (and gauge the results as you go); OC on the other hand, with its far worse tendency towards bureaucracy, will result in irrevocably going from the frying pan into the fire.

J Pahnke said...

D: Obamacare is very complex... because of political compromise. You've not responded at all to the real concerns in the post... that the incentives insurers claim are not aligned correctly and the complexity generally serves to deny coverage and drive up costs.

A: Leaving aside the only way Democrats could think of reforming health care was to create a 2700 page bill with multiple new federal agencies and bureaucratic departments to control every health related decision made in America-- the old Russian Politboro would be proud!-- I find your position plainly contradictory. On the one hand you admit that Obamacare is very complex and concede that increasing complexity “drive[s] up costs,” yet on the other hand insist this behemoth of a bill will lower costs, an untenable position.

Finally, to blame OC's complexity on “political compromise” for a bill passed on a straight party-line vote is indeed curious for those who like to invoke the “rights of the minority.” There may have been “compromises,” but it wasn't with Republicans. Indeed, the fact that such concern came from the President's own party should tell you all you need to know. But I won't hold my breath. jp

J Pahnke said...

The recent decision by the Cardinal Glennon Children's Hospital in St. Louis to accept for treatment Baby Joseph, (see separate 3/15/2011 post on this issue at, only underscores that my initial concerns and assessment in the ongoing debate over repealing Obamacare is correct.

Aside from the very dangerous and barbaric precedent that the Ontario Superior Court attempted to here establish of forcing the “consent” of Baby Joseph's parents to remove his breathing tube regardless of their wishes and beliefs that doing so was wrong (and would unnecessarily and prematurely snuff out baby Joseph's young life and chance for further treatment), this development conclusively demonstrates the inherent risks in the government holding such awesome power over individuals' health care, (a situation we are well on our way to with Obama style "health reform" in this country). And this is true no matter how "scientific" or benevolent its motives may be in providing such health “care” to its citizens.

I additionally note the irony and interesting contradiction in Doug's stance at the ACLP blog on another subject, quote "I still don't get why you think Obama should be required to defend something he disagrees with" (regarding the DOMA), compared to his stance re: Baby Joseph. "So what does one have to do with the other?" you may ask.

Simply this: You express your concern that President Obama should not be "required" (your word) to defend the laws of our country duly-passed by the Congress under our Constitution, yet you won't give the same deference to the parents of Baby Joseph, (who would have been REQUIRED to violate their consciences, to say nothing of their rights as parents!), in "consenting" to end the life of their own child. Interesting contradiction indeed... jp

Shak Olreal said...

The big question is how incentives are supposed to work with something as complex as health insurance. The various details of health care plans from which I could choose is available online somewhere, but the side from which to make voters do monthly prizes. With so many moving parts - a network of franchises, out-of-network deductibles, co-pays, coinsurance, exclusions and so on - How to ensure that we are that people can process information needed to make rational choices, even if they have to click through information on the different plans? I have learned that many of these details when the facts because (and only because) I was willing and able to take the time to browse through the paperwork and spend time on the help line - talk to someone who has admitted he could not understand it either!Eden GoldBuy Eden GoldCheap Eden GoldEden EternalEden Eternal GoldEden Eternal Review

RS Gold said...

There is nothing worth the wear of winning, but laughter and the love of friends.
The fist rule for making Cheap WOW Items is to buy low and sell high. This method works well in buy eden gold people’s game play.

cheapriftgold said...

Lengthy ago i found the article and have absolutely also been reading along. I wish to verbalize this wonder of your respective authorship science in addition to chance to shuffling viewers learn right away towards the goal. I'd really like to learn to read new blogposts as well as share this feelings with you.

RS Gold
MapleStory Mesos

J Pahnke said...

At the risk of dilution of the seriousness of my comments, (following all the commercial spam, albeit it's reassuring that some of the problems I had previously here might NOT have been motivated by left-wing bias), I would like to make this final observation as a follow up.

It is now indisutable that Baby Joseph, the Canadian child denied care under Canada's vaunted single payer system, has flourished due to the health care he received in America's wicked and "unjust" system of health care delivery. Yes, this is the same child who you would have condemned to death in Canada because the government thought it such a "waste" to help such an obviously "dying" child. Of course, the child will eventually die, (as we all will), but are you still as comfortable letting the government have this awesome power of life and death? (and one from all indications will be exercised for largely "economic" reasons?) We are indeed on a slippery slope towards mass violations of the rights guaranteed by the 14th Amendment to ALL citizens when America's finest legal minds see no cause for concern in these matters. jp

johnson said...

which still suffers from huge economic uncertainties and local concerns about safety, had been growing in acceptance as what appeared to many to be a relatively benign the cambridge satchel|satchel cambridge|cambridge satchel|cambridge satchel company|the cambridge satchel company|cambridge satchel bags|cambridge satchel company bag|cambridge leather satchel|women ugg boots on sale|英文seo

WowGoldEu said...

There are abounding things that can accomplish you feel glamorous, but what's amiss with activity alluring everyday? A brace of admirable bargain Christian Louboutin Wedges can accumulate you activity calmly aces every day this summer. Be accessible with these christian louboutin shoes. A advanced array of styles and colors to accommodated every taste, these will accept you searching admirable in the summer. Perfect for the woman searching for a accidentally chichi look, these designs can be beat accustomed with basal accomplishment and actualize a able and contemporary style.

sanatesiwow said...

If you have enough black bags, maybe you want something different. You can find that here also. They have bags in every style and color to fit every taste and lifestyle. The hardest thing you will have to do is to choose only one, so do not just stop at one. Snakeskin embossing is used on a variety of these backpacks and bags.louis vuitton monogram handbag
louis vuitton handbags
louis vuitton monogram handbag
louis vuitton handbags

Unknown said...

Set aside the question of whether we should have a universal single-payer national health plan, or a public option, or (at the other end of the spectrum) replace traditional Medicare with vouchers. Set aside also disagreements over the constitutionality of the 2010 health care law. Focus instead on the current system of health insurance in the United States.