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Tactical Ninja - Thoughts on the public good and why half-and-half healthcare doesn't serve it

Jul. 18th, 2014

10:16 am - Thoughts on the public good and why half-and-half healthcare doesn't serve it

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So I got a letter last night from the rheumatologist. To summarise, they are underfunded and only taking 'the most urgent' cases. They regret that they can't offer me an appointment. They realise that this will probably cause me some distress, but they wish to be honest, and I should go back to my doctor to discuss my options.


This is the first time in my life I have ever been refused a health service. I have, previously, been put on waiting lists for non-urgent specialist care, but never before have I experienced the feeling that goes with "We are not going to help you at all, ever."

Now, I am one of the lucky ones. Financially, I'm in a position where I can afford to see a specialist on my own dime. Only just - specialists are expensive - but I can, and it won't mean going hungry or getting behind in rent. I consider myself to be privileged in that sense. I actually do have options to discuss with my doctor at $65 a pop. If I were poor, I would probably be screaming right now.

Which brings me to a question. What exactly constitutes 'the most urgent'? Is it people with higher counts of antibodies than me? More symptoms than me*? Or people whose health records show they qualify for a community services card and therefore could not afford to pay for private healthcare? My guess is that it's probably a combination - perhaps if I were poorer I'd get an appointment, or if I were more immune-full I'd get an appointment.

Either way, I don't get an appointment, unless I shell out to go private. Do I need to pay another $65 to see my doctor to find out my options?

1. Don't take it any further, wonder forever what the fuck's wrong with me, put up with symptoms.
2. See doctor, decide to investigate other options without seeing specialist.
3. Pay out of my own pocket to see a private specialist.

At this point I will probably go with 2. I have a couple of ideas for things that could be looked at before going down the RA/lupus track. I'd like to do that without the exorbitant fee if possible.

It's nice to have options. It's also kind of nice to know that they are still taking 'more urgent' cases than mine. But it really bothers me that I was refused state healthcare, and that my refusal is based on underfunding. See here's the thing.

I pay tax. I pay the most tax you're supposed to pay in a graded tax system. I'm one of those middle class they keep talking about - high income, high tax, but not able to dodge tax like a business owner is able. I pay more tax than the rich, generally. I have a fair amount of disposable income, but the fact remains that I'm in the highest tax bracket and thus pay more into our shared pool than many people. I don't begrudge that. In fact, I've often said I'd happily pay more tax if I knew it were going to be used for things that make everyone's life better - like education and healthcare.

I'm one of those wankers that buys the top-tier-cost ticket to Kiwiburn because I believe that those who can afford to, should. I quite like that in our socialised healthcare system, I pay more for the doctor because I can afford to pay more, and someone with less income pays less. I think that's as it should be.

The problem, for me, is that our healthcare system (and education, but that's a different rant) is becoming less socialised. We still all pay into a coffer, and most healthcare is still subsidised, but we have this weird hybrid system where you can choose to pay for health insurance and that allows you to jump the socialised healthcare queues for non-urgent things by going private. This means that since the 1990s, private hospitals have sprung up everywhere. The government, meanwhile, seems happy to continue to shove its head up the US's arse and this is threatening (through the TPPA) our subsidies on medication. I found out from the lady who took my blood the other day that the government is 'urging' doctors to request fewer blood tests - blood tests being one of the few things that's still completely covered. She thinks it's a precursor to bringing in user-pays on that as well.

So why is this a problem for me? I mean, apart from the obvious thing that the US has the most expensive and least effective healthcare system in the Western world, so copying them is just stupid, I mean.

You know what I was saying about the upsurge in private hospitals? Well, they are being used by very specific groups of people - those with insurance, and those with the income to pay up front. In other words, people with disposable income. Or, to put it another way, the well-to-do. You don't have to be quite as well-to-do to have medical insurance, but you have to be able to afford the regular payments and that cuts out anyone earning below about $40,000 (which is more than half of the country, btw).

So you end up with two separate health services - the one used by the wealthy, and the one used by the poor. The wealthy have a choice whether to go on a waiting list for the funded service, or to get seen quickly by paying extra. The poor have no such choice.

Now you'd think this would be a good thing because it'd take the people who don't really need the subsidy out of the public system and leave more spaces for those who really need the help. But I get the feeling that what is actually happening is that the government is using the increased usage of private healthcare by the wealthy as a justification for reductions in funding to the public system, in the guise of 'streamilining' services. So the more people like me who end up going private, the less the government gives to fund public rheumatologists, so the fewer people they can see, so the higher they put the benchmark for how sick you need to be to get seen, so the more people like me end up going private and altering the usage stats..

You can see where that leads - to an underfunded public system that is refusing healthcare to people who are paying into it, which forces them to pay again for private healthcare. Thinking about this situation is the first time I've felt resentful towards our public healthcare system - because while I'm happy to pay my share, or more than my share, the minute I'm told that I'm not going to receive a service *at all* for my money, I start to wonder why I'm paying.

I'm not stupid, and I like to think I'm compassionate. I'm aware that my Mum used far more dollars' worth of healthcare when she was sick than our entire family probably paid into the system. I'm glad that my 'place' at the rheumatologist is going to be given to someone who needs it more than me. But I'm not representative of people in general. Many many people, especially it seems rich people, would simply go "I am paying for a service I'm not getting, and I don't want to keep paying for it." So you get tax dodgers, which reduce the tax pool, which reduces the amount given to the public health system, and so on and so forth.

Sound familiar? The development of separate health systems - a good, effective and timely one for those who can afford it, and a slow, underfunded and overworked one for everyone else. It's like every dystopian future movie ever. And we're doing it to ourselves by having a half-pie socialised healthcare system that allows rich people to pay for better treatment.

Oddly enough, I finished Michael Sandel's book Justice yesterday. The book essentially discusses three main ideas of what justice is:

1. Justice is doing the thing that has the most utility (benefit) for the most people. Socialised healthcare would normally come under this. So I pay more tax cos I have more money. My money goes to fund the health system, and we all get to use it. It's a small reduction in benefit to me, which provides a larger benefit to a larger number of people.

2. Justice is doing the thing that provides the most freedom. Entirely private (free market) healthcare would come under this. People can choose what level of healthcare they receive, including to not receive any, and they can negotiate for themselves what they are willing to pay for it. Nobody's being forced or coerced into paying for something they aren't using.

3. Justice is doing the thing that is most in line with the living of a good life. This involves deciding what a good life is, and making moral judgements about what is good and right. This approach is generally avoided by people when talking about political issues, because we struggle a great deal to agree on morals, and it's generally accepted that forcing one's morals on another is 'wrong'.

In terms of healthcare, what does a good life mean? Does it mean that everyone gets the healthcare they need regardless of their income, and everyone is required to pay whether they need it or not? Or does it mean doctors are paid sufficiently well by those who use them to ensure that high-quality healthcare is always available, and people can choose for themselves whether to pay the fees?

I had a really hard time typing that second sentence. Sorry, I'm a filthy socialist, and I firmly believe that we are all in this together, that there is absolutely no such thing as a truly free market, and that if we're going to have socialised healthcare that means we should have UNIVERSAL healthcare. To me, this means that it should be sufficiently well funded that *everyone* gets to use it in a timely manner regardless of income, and that those of us with higher incomes should pay more into it because we can afford to, because looking after each other is the right thing to do.


And this is the basis of my resentment. This half-pie thing we have in New Zealand is not working, because I was refused healthcare that I am paying more than most people for. I am being directed by this system to shun the public good that I put 30% of my income into, and instead to use my privilege of income to pay for more privilege, which separates me further from any vested interest in helping support public health. I am trying to do the right thing, and it's being subverted into the complete opposite of what I believe is a good life.

I can see that someone who was less stubbornly determined to live by their principles than me, would very easily think "Why should I pay into this at all? It's not as if I use it!" and start working out ways to pay less into the public good. And from there, it's not hard to see how a class of wealthy people with zero interest in furthering the public good can become so detached from the concept of shared wellbeing that they no longer feel any sense of social responsibility - which leads to being completely ok with some people being unable to have the same access to quality of life that they themselves have.

I think Sandel is right. There are some issues that can't be effectively discussed without including moral judgements about what is right and good. And in my opinion, 'the good life' is one where we are all invested in each other's wellbeing, where we share difficult burdens and where those who have advantages use them to make everyone's life better. I would happily pay more tax if I knew it were going to make sure everyone gets to see a rheumatologist when they need one. But everyone includes me, and our system is excluding me because the tax I pay is not going to universal healthcare. It's going to fly ministers to the US to discuss dodgy trade deals - made by people who can afford to go private - that will put healthcare even more out of reach for most kiwis. But probably not me, because I have a high income. So that's ok, right? Because choice is justice!

I don't think the current managers of our healthcare system have the same view of what is good as I do, somehow.

* I have had moments since I got that letter in which I've berated myself for being a hypochondriac. Maybe I'm not really sick enough to warrant wasting valuable healthcare resources finding out what's wrong with me. But then I remember that I've been waking up in pain every day for the last 10 months - pain bad enough so that I've on occasion needed help to get dressed - and that the only reason that right now I feel ok enough to question myself is because I'm taking twice-daily doses of a medication that'll eventually destroy my stomach. I deserve healthcare. I have to keep telling myself this.

Comments:

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From:pundigrion
Date:July 17th, 2014 11:04 pm (UTC)
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I am utterly opposed to any healthcare privatization for exactly the sort of reasons you are pointing out. It leads to second rate care for nearly everyone. Even if you can afford to go private, you are more likely to put it off and not get as much preventative care unless you are very rich indeed as well.

I have very similar Strong Thoughts on the private school voucher programs or publicly funded Catholic school boards.
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From:tatjna
Date:July 17th, 2014 11:07 pm (UTC)
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My very first university essay was about why the education system shouldn't be run like a restaurant (which at the time was what one of our politicians was suggesting should happen).

Right now, our government is paving the way for charter schools, and last budget increased funding to private schools. To which I went "Wait, private schools are getting public funding? WUT?"






Edited at 2014-07-17 11:07 pm (UTC)
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From:pundigrion
Date:July 18th, 2014 02:43 pm (UTC)
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Yep, we've had to fight with that here too. Drives me nuts.

Is there no country that is not actively dismantling their public health/school/social systems?!
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From:c_maxx
Date:July 21st, 2014 04:32 pm (UTC)
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WUT? indeed!

I heard an honest person on Public Radio back when George W was elected [we had talk of a "compassionat initiative", i.e. reduce public support, aid to families, etc, by giving some money to churches to replace government aid]:

A true-blue Texas Baptist minister: "I don't want any of my tax money going to the Branch Davidians (a nutso Texas cult), and there are probably honest folk out there who don't want their tax money going going to the Baptists either!"
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From:c_maxx
Date:July 21st, 2014 04:32 pm (UTC)
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WUT? indeed!

I heard an honest person on Public Radio back when George W was elected [we had talk of a "compassionat initiative", i.e. reduce public support, aid to families, etc, by giving some money to churches to replace government aid]:

A true-blue Texas Baptist minister: "I don't want any of my tax money going to the Branch Davidians (a nutso Texas cult), and there are probably honest folk out there who don't want their tax money going going to the Baptists either!"
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From:ferrouswheel
Date:July 17th, 2014 11:06 pm (UTC)
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Justice is someone I care very much about not having to wake up in pain everyday or be on pain medication. But I might be impartial here.

I would pay for private, because health is important and it's easier to effect change when you're not fighting against one's own body. I think universal health care is the better option, but I feel martyring one's wellbeing on principal could make it harder to fight for things later.

Also, if you've already applied and been rejected, then that should be in the health records too. I'd also question whether private can report your decision to go private to the government. If they can, is there a way to opt out of the data collection?

(+ congrats on finishing the book! ;-) )
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From:tatjna
Date:July 17th, 2014 11:09 pm (UTC)
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<3

I will only go private if it becomes necessary after exploring all my other options.

I honestly don't know how such data is collected - I'd imagine it's from the records of visits kept by each provider.
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From:fbhjr
Date:July 18th, 2014 12:07 am (UTC)
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Wow.
I very much hope you don't end up with what we have here in the states. It is not very good at all.
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From:tatjna
Date:July 18th, 2014 12:09 am (UTC)
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I hope so too. At one point in my life I would have laughed at the idea, but in the last few years our Third Way politics have taken a sharp turn for the neoconservative, and now all bets are off.

There's an election here in September. The outcome of that may give us a chance to slow the pace of the nastiness, but I believe at this point that we're unlikely to ever get back to universal healthcare.
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From:fbhjr
Date:July 18th, 2014 12:12 am (UTC)
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At least here in the states the problem is the folks who most need it have the least political power. So, things tend to favor the other end.

And, I should mention, I hope it works out for you!
Sorry I didn't say that in my first comment. I got to involved in the politics at the end to remember it has a direct impact on you right now.

In very much other news, I read this the other day and thought of you:
http://madartlab.com/fantasy-armor-and-lady-bits/
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From:tatjna
Date:July 18th, 2014 12:19 am (UTC)
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Yep, same problem here.

And thanks for your well wishes. I've no doubt I'll get to the bottom of it one way or another. ;-)
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From:pixiebelle
Date:July 18th, 2014 12:29 am (UTC)
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I'm a filthy socialist too, so I after that moving to the U.S system is a very bad idea. It's horrible here, ridiculously expensive and not getting any better. One reason I chose to stay in expensive-as-hell California is I get few healthcare here. It sucks, and I'm still waiting two months later to get it and my options for doctors are limited... But had i moved to cheaper Missouri, I'd have to pay $250 a month for shitty healthcare and it's now technically required by law that I have it.

Plus, I actually do need it. </p>

My hope is we finally get a socialist-leaning president in my lifetime... But I'm not holding my breath.

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From:beagl
Date:July 18th, 2014 12:48 am (UTC)
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You've got some thought provoking stuff in there and an interesting analysis of the larger political situation.

However, I think there is one big factor you've left out - can we even afford to pay for as much health care as everyone wants? It's generally considered that the public appetite for healthcare is nearly bottomless, so there's always a need to balance out what we're prepared to pay with the services that we can offer.

Once you've done all the Pharmac-style optimising (basically trying to get best bang for buck) and there are still services that people want but you can't afford... what should we as a society do?
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From:tatjna
Date:July 18th, 2014 01:07 am (UTC)
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That's a good question, which I'd answer by suggesting that we have a look at the priorities in our spending, and vote in a government whose policies most closely match those.

So for me, not one that believes in freemarket economics coupled with conservative social policy.

However, I think the question itself is interesting because I don't think we are in that situation. I think there are plenty of places where NZ could tighten its belt before reducing access to healthcare. Like, subsidising farmers, or tax breaks for offshore companies for the sake of bringing their business here (WB), or hosting expensive sports events.

I know there's an argument that those things bring in money that helps pay for healthcare, but I'm not convinced by it when I see reduced access in the wake of said things.

Additionally, I think there's a difference between the healthcare everyone wants and the healthcare everyone needs. Right up until now, I've believed that in NZ we've had that balance pretty good in terms of cost vs user pays vs wait times. Like I said, this is the first time I've sought healthcare and been refused it outright - which says something's changed.
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From:dragonvyxn
Date:July 18th, 2014 03:03 am (UTC)
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i'm a total socialist as well, so i agree with you on all this. sounds like a shitty situation for you to be in, and i hope that you can get the care you need!
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From:tatjna
Date:July 18th, 2014 03:08 am (UTC)
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Luckily for me, I can. Luckily for me, this up here is just a thought experiment.

I read so many stories like this from the US, only instead of them ending with "Luckily for me" they end with "I don't know what to do."

I really really don't want our country to follow the US format for healthcare.
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From:danjite
Date:July 18th, 2014 08:28 am (UTC)
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Oddly, I am too sick to get a deep comment across here, so will focus on one point. My venerable and wise father has given me advice 3 times in 49 years. The last piece of advice was this: If there is something wrong, see a doctor immediately. Getting in early can both make a difference to efficacy of treatment and just save mystery and misery.

It has sometimes cost me a bunch to do so, sometimes when it wasn't ideal. FOr me, it was always the right thing.

For now, I vote strongly for pay out of your own pocket to see a private specialist. End the mystery.
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From:kotturinn
Date:July 18th, 2014 12:20 pm (UTC)
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With only a few minor alterations this could be the UK. The main differences, as I see it, is that we are further down the WUT? route than you as regards schools, but not yet so far down it on healthcare. Yet. Our tax and benefits system is an almost complete f* up now on account of it being easier (read: less likely to lose votes) to take away from the poor than the individually wealthy snd the companies. Unfortunately, none of the 3 main political parties have the will to make it any other way. And yes, it's wrong, wrong, wrong. I appear to be in a very similar situation to you wrt affordability and viewpoint. I alternate between being so glad I'm not younger and so very worried about my nieces (in their 30s) and the great-n's (all under 10).
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From:spotsofcolour
Date:July 18th, 2014 01:40 pm (UTC)
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It sounds like the NZ healthcare system is in a very similar state to the UK one. I've been very fortunate in my use of it, by and large, but I have to say I'm now struggling to get a diagnosis for an ongoing problem and there doesn't seem to be the level of interest in the public healthcare system to really try to work it out. I'm just getting a lot of "Well we're out of ideas now, so there's nothing else we can do" rather than pushes to try and find out what it could be instead.

If I were on my own, I definitely wouldn't be able to afford private healthcare to try and work it out. But fortunately I have the support of my parents, who are pushing to try and go private if the NHS keeps coming up blank. But I feel like I shouldn't have to rely on my parents' money to try and get treatment for a condition, just because the NHS can't be bothered to work out what it is.

And then the longer it goes on, the less effort I'm able to put into pushing for answers, feeling like I'm being blocked at every turn and that no-one cares. It's pretty awful. I guess we're in the same boat in that sense - we both deserve the healthcare and we both need to keep pushing for it!
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From:meathiel
Date:July 18th, 2014 01:49 pm (UTC)
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My sentiments exactly ...
Seems the health service is the same sh** everywhere!
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From:meri_sielu
Date:July 19th, 2014 03:45 pm (UTC)
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I'm really starting to get worried about the NHS and the way it seems to be turning into the abysmal health system of the US more and more by the day. It sounds a bit like your health service is going that way too. :/ I hope you can work it all out without the extortinate fee somehow.
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From:c_maxx
Date:July 21st, 2014 04:35 pm (UTC)
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Our half-pie thing does not look to work any better as well...

Agree about UNIVERsal health care!
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From:helianthas
Date:July 22nd, 2014 06:36 am (UTC)
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In the US, the middle class folks are who really get screwed. Upper can pay, and poor actually do get excellent treatment, at least here in California, even if they do have to wait a while.

I've been off LJ for quite some time, so not sure what sort of pain you're suffering with. RA has pretty obvious visible joint symptoms, but I believe there are many blood tests that can be ordered by your GP to check for other autoimmune disorders. Sedimentation rate is one, can't remember the others but I can try to look up the tests they did for me, or if you google perhaps you can go armed to your GP to get the blood tests done without a specialist, and if anything is fishy then try for another referral.</p>

There is also a very good book called "healing back pain", I actually listened to it and the author had a hilarious New York accent that made me want to listen even if I didn't totally believe it, so I recommend the audiobook. After listening, my ankle ligament, which had been injured for 6+ months, miraculously healed itself. Possible coincidence -- I'd quit babying it so maybe the exercise helped -- but I think the book had a lot of really good points.

Good luck!

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From:helianthas
Date:July 22nd, 2014 06:36 am (UTC)
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In the US, the middle class folks are who really get screwed. Upper can pay, and poor actually do get excellent treatment, at least here in California, even if they do have to wait a while.

I've been off LJ for quite some time, so not sure what sort of pain you're suffering with. RA has pretty obvious visible joint symptoms, but I believe there are many blood tests that can be ordered by your GP to check for other autoimmune disorders. Sedimentation rate is one, can't remember the others but I can try to look up the tests they did for me, or if you google perhaps you can go armed to your GP to get the blood tests done without a specialist, and if anything is fishy then try for another referral.</p>

There is also a very good book called "healing back pain", I actually listened to it and the author had a hilarious New York accent that made me want to listen even if I didn't totally believe it, so I recommend the audiobook. After listening, my ankle ligament, which had been injured for 6+ months, miraculously healed itself. Possible coincidence -- I'd quit babying it so maybe the exercise helped -- but I think the book had a lot of really good points.

Good luck!

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From:barrelofrain
Date:July 28th, 2014 04:00 pm (UTC)
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You totally 100% deserve healthcare.
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