Health care: Who is looting us, the people?

SATURDAY, DECEMBER 3, 2011

Even Samuelson fails to explain: On Thursday, we complimented Robert Samuelson for this column about the cost of health care.

In his column, Samuelson cited the latest data from the OECD. For us Americans, several major policy problems are wrapped up in these remarkable figures about health care spending:
Per person spending on health care, 2009 (or nearest year):
United States: $7960
Canada: $4363
Germany: $4218
France: $3978
United Kingdom: $3487
Australia: $3445
OECD average: $3233
Italy: $3137
Spain: $3067
Japan: $2878
Good grief! Why do we spend $8000 per person for health care when other major developed nations spend so much less? As Samuelson notes, our health care outcomes are no better than theirs!

Why do we spend so much more? Whatever the answer may be, other major policy problems are tangled up in those remarkable data. Two examples:

The ongoing debt/deficit problem: As Samuelson notes, health care accounts for 27 percent of all federal spending. This leads to the point Dean Baker made in praising Samuelson’s column: “The long-term deficit problem is primarily health care, health care, and health care.” What would happen to our future deficit problem if health care spending in this country matched that in other developed nations? Baker often makes this truly remarkable point:

“If we paid the same amount per person for our health care as people in other wealthy countries, we would be looking at long-term budget surpluses rather than deficits.”

Amazing! Our excessive health care spending accounts for those annual deficits!

Stagnating wages: As analysts often note, the rising cost of health care also accounts, in large part, for our stagnating wages. Employers are forced to pay more and more for their employees’ health care. This keeps employers from being able to increase employees’ wages.

Simple story: Our remarkable health care spending is all tangled up with other problems. This raises a basic question: Where is all that money going? Why do we spend twice as much on health care as comparable nations? Twice as much, sometimes more?

Where is all that money going? As a general matter, major news orgs have long refused to address that seminal question. (We repeatedly noted this group silence during 2009.) Samuelson went much farther than most. But even so, a major problem still lurks in his two-part “explanation:”
SAMUELSON (11/27/11): What propels U.S. health spending upward? The OECD’s answer comes in two parts: steep prices and abundant provision of some expensive services. In 2007, an appendectomy cost $7,962 in the United States, $5,004 in Canada and $2,943 in Germany. A coronary angioplasty cost $14,378 in the United States, compared with $9,296 in Sweden and $7,027 in France. A knee replacement was $14,946 in the United States, $12,424 in France and $9,910 in Canada. Knee replacements in the United States were almost twice as common per 100,000 population as in the rest of the OECD. So were MRI exams and angioplasties.

This is a devastating portrait. At times, the U.S. health care system delivers the worst of both worlds: pay more, get less. Unfortunately, the message isn’t new. America’s fragmented and overspecialized health system maximizes returns to providers—doctors, hospitals, drug companies—but not to society. Fee-for-service reimbursement allows providers to reconcile their ethical duty (more care for patients) and economic self-interest (higher incomes). The more they do, the more they earn. Restraints are few, because patients and providers both resist limits on their choices. Government regulators and private insurers are too weak to control costs.
Why do we spend so much more? Samuelson gives two answers. First, we provide more services than other nations. Second, those services tend to cost much more in this country.

According to Samuelson, an angioplasty costs $14,000 over here. It costs half as much in France.

This topic is simply never discussed by our big mainstream news orgs. Samuelson went much farther than journalists typically do. That said, he’s still largely begging the question in this informative passage. He says that basic procedures cost much more in this country—but he doesn’t say why!

Why does that angioplasty cost twice as much in this country? Where's all that extra money going? Samuelson makes no attempt to say—and he’s providing a much fuller discussion than you normally find in the press!

Our big news orgs have long agreed; they must never discuss this matter. Samuelson goes way over the line—but even he begs the basic question:

Where is all that money going? Why do basic health care procedures cost so much more over here? Let's express ourselves more plainly:

Who is looting us, the people? When will someone explain?

42 comments:

  1. Bob Somerby claims that medical practitioners are "looting the people", because they're paid a lot better in this country. But, many jobs pay a lot more here than overseas. E.g., auto workers, university administrators, university faculty, government employees, postal employees, truckers, railroad workers, and most other Americans earn a lot more than their overseas counterparts.

    Would Bob say that workers in all these areas are "looting the people"? I don't think so.

    BTW, if high cost eqates to "inefficiency", American government is one of the most inefficient areas in our economy. That record suggests that government medicine will not produce the kind of cost improvement that its proponents expect.

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  2. This is a subject that needs to be pounded and pounded until the mainstream media gets it. Keep asking these questions and maybe we can do something intelligent about health care costs.
    I'm not holding my breath, however.

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  3. If one wants to study whether governemnt medical care in the US would be cheaper than private care, it's crude to compare total US medical costs against other countries. After all, half of US medical costs are paid by the government. Maybe it's the government half that's so expensive.

    A more useful comparison would be to split between people younger than age 65 vs. those 65 and older. The older group is pretty much on Medicare. I would guess that such a comparison would show that the over-65 Americans spend more, relative to our foreign counterparts, than the under-65 group. The reason I think so is the enormous increase in my own medical spending since I've been on Medicare. I find myself making greater use of medical practitioners.

    I might add that all this medical care is making me healthier. However, most of the benefit goes to improving my quality of life, rather than extending my life.

    Also, my threats of dying don't necessarily come from medical conditions. E.g., last year I spent a couple of days canoeing on the Zambezi River with crocodiles and many hippos. Had I died on that outing, it wouldn't have been the fault of American medicine.

    My personal experience suggests that simply comparing average life spans isn't that good a way to compare medical effectiveness.

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  4. David in Cal: Where does Bob Somerby claim that 'medical practitioners are "looting the people", because they're paid a lot better in this country'? He certainly doesn't say that in this post. If he said it somewhere else, please provide a link.

    In his final two paragraphs here, he, in fact, asks WHO is looting the people.

    Are you aware of any source where this discrepency in medical costs is analyzed and the reasons for the differences are laid out? This would be very useful information, but I've never seen anyone really attempt it. It would, of course, be most helpful if the relative impact of the different sources of those cost discrepencies was indicated. Has anyone even tried to do this?

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  5. David in Cal; There you go again with the age old right wing mantra: The government is to blame. In England, the government totally runs healthcare. In Canada the Government is the payer of healthcare.
    Why don't you wake up and do some reaerch?

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  6. There is no mystery none at all, why health care in the U.S. is so much expensive, both on a procedure by procedure basis, and as an aggregate cost, than anywhere else.

    1) American healthcare delivery is a for-profit business. Providers will charge as much as they can get away with. This is simply not true in other countries -- healthcare is obviously a source of personal income elsewhere, but it's not regarded as "freee-market" profit-driven industry, any more than the post office is. The one exception to for-profit medicine in the U.S. would be the Veterans Administration, and it's costs are substantially lower than that of the U.S. as a whole, with equal or better outcomes.

    2) a glaring and perverse incentive built in to the system to offer expensive and unnecessary care, because it increases provider income, as noted by Samuelson.

    3) the drug lobby, which makes Americans pay far more for drugs than does the rest of the world despite, in many cases, development costs underwritten by the taxpayer.

    4) insurance companies typically skimming 20% to 30% right off the top.

    Where the hell is the mystery in all this?

    ReplyDelete
  7. Oh, and another one:

    5) a culture in the U.S. which celebrates the wit of those who successfully game the system to get rich. For all the talk of class warfare, we celebrate business people who would be regarded as parasites in healthier societies.

    ReplyDelete
  8. Thanks for coming back to this topic over and over. Let the Howler howl! And Howl! Whooo!!!

    ReplyDelete
  9. A personal experience-I had a kidney stone attack.No insurance.Went to the emergency room,. Needed a CT scan-$4000.Attack subsided(turns out I passed it while waiting 2 hours in EXCRUCIATING pain)Thanks,I'll see a urologist tomorrow.Urologist says CT will be $2000.Thanks, I'll see a friend of mine who brokers MRI/CTs.He sets me up w/a lab for $250 (cash). It took a couple days to schedule so I called 2 other labs-they would do it for $275 (cash) My friend tells me the insurance companies/doctors pay him $5-600 to schedule these proceedures. The uninsured are to be raped (his words)
    Conclusions: Hospitals charge the most to offset uncollectable / good profit for required service.Doctor charges less but offsets uncollectable with good profit I would have paid twice as much.Insurance companies appear to pay a lot for services on behalf of customers yet don't.
    In possibly related story,I need a heater coil for my truck. Dealer wanted $600 for part/$900 labor.My dash has to partially come out-youtube video shows how-3 hours. Part at O'reilly is $60.
    I am the do-it-your-selfer.(Is there a youtube for angioplasty?)

    ReplyDelete
  10. Hi,

    Try this link for PBS's Frontline's show comparing a few advanced countries' health systems --> http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

    ReplyDelete
  11. Anonymous-you have been doing your Howler homework Can David in Cal copy your notes?

    ReplyDelete
  12. I answered this a few days ago, I guess no one went there.

    Thursday, September 3, 2009
    Show me the money!

    I have been hearing a lot about the cost of healthcare in the US, so I decided to look up some facts and figures.

    Compared to 17 other industrialized nations (OECD nations that are developed, free market countries), the US consistently spends twice as much per person for the same level or even poorer healthcare. These other countries all have nearly universal coverage, but they manage to give healthcare equal to or better that the US while spending only 40-60% as much per person. US average annual cost $7920. Average of OECD developed nations: $2964

    If we’re paying twice as much, where does our money go? Nobody is telling us that.


    Try these numbers for size.

    Industry estimates are that 20 to 25% of health insurance costs are for filing and paying insurance claims. Outside estimates place that as high as 35%. Estimates are that overhead for management and marketing for private insurance companies is more than seven times greater than for Medicare and Medicaid, arguably at 2 to 5%.

    It is well known that Medicare pays out millions in fraudulent claims, but more stringent accounting can cut these losses. Healthcare providers defraud Medicare, but in the case of private insurance, the insurance companies themselves commit the fraud on the public.

    Profits for 10 of the country’s largest publicly traded health insurance companies rose 428% from 2000 – 2007, while consumers kept suffering cuts in coverage. For the top five, that comes to $11.77 billion for 2007 alone. Insurance company profits are more than 5 times the average of Fortune 500 industries, and 5 times the rate of inflation.

    Health insurance lobbies paid politicians $2.79 billion in 2007, and in the first half of this year they have paid out nearly $35 million, and that’s what they admit to. Going by the news stories about Congress, it looks like money well spent.


    In addition, drug industry profits for the top 10 companies were in excess of $50 billion in 2006.

    What happens to the money? Well, we all know how top executives reward each other. I won’t go there. Shareholders get an estimated 6%, as do shareholders in insurance companies.

    But what about expenses such as merchandising and advertising?

    In 2006, the top five companies spent $48.2 billion. (And money spent on ads aimed directly at consumers is tax deductible, hitting the public with a double whammy.)

    Some of this tax-deductible money was used to promote non-approved use of drugs in a clear violation of FDA regulations. Drug companies have had fines of more than $11 billion levied over the past decade for these violations. Pfizer was just fined $2.3 billion in such a case. Drug companies continue paying these fines because their profits are so vast that these fines are merely one of the costs of doing business.


    The top ten spent $24.415 billion on lobbying in 2006. Yes, lobbying. That’s why Medicare can’t bargain with drug companies, but the VA can. Lobbying gets the most bang for the buck by far. Pharmaceutical industry profits increased by over $8 billion in the first six months after the Medicare drug plan went into effect (2006). No other investment could possibly beat those returns.

    It’s too bad Americans can’t get as good deal from our elected officials as the insurance and drug industries get.

    We spent $2.24 trillion on healthcare in 2007, $2.38 trillion in 2008 (HHS data). 2010 estimates hover around $3.1 trillion.

    What would our healthcare and drug company executives be willing to do to get their hands on that, and what are our elected official willing to do the stop them?

    11/03/2009

    Addendum: This does not address actual medical expenses. That is next.






    Posted by gravymeister at 10:53 AM 0 comments Links to this post

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  13. Other Benefits


    At one point, I was diagnosed with a bone spur on my Achilles’ tendon. I was given a script for Vioxx[1], and sent to physical therapy.

    The physical therapist used stretching, massage, electro-stimulation ultra-sound, heat, and cold, and told me to do exercises and use icepacks at home.[2] I went 2-3 times a week. Every 2 weeks, my therapist (there were three partners in the cabinet,) would ask me for my card, ask for €40, and enter it into his computer. In a few days, 28 would be deposited to my bank account.


    Flu vaccines were available at the start of flu season. You would go to your pharmacist and buy the vaccine for €6 a dose, (free if you were over 55 and a resident of the Vaucluse, the Department we lived in.) You took the vaccine to your doctor and he or she would administer it for the OV fee of €20. My wife’s doctor would do us both for the price of one. Again we got the€14 refund.

    Back In The USA


    Now for the reptilian-brain side of my story, back on the US. Memorial day weekend, 2006, I came down with a sore throat that was so bad, I was unable to swallow. It was by far the most painful sore throat I had ever endured. I carried a cup around so I could spit out my saliva every few minutes.


    My wife was out of town, and my doctor’s office was closed for the holiday weekend, so I went to the nearest hospital emergency room.

    They did not do a throat culture. They prescribed a three-day miracle antibiotic, which was absolutely not indicated for this ailment and ineffective, plus massive doses of Ibuprofen, which did not relieve the pain at all. I went to my Doctor as soon as he returned, and he treated me with an effective antibiotic, and steroids to reduce the swelling. Meanwhile the massive doses of Ibuprofen cased an acute attack of gout in my right toe. Which took me back to the emergency room, (it occurred on a Friday night, and the pain was crippling.)

    I was given two prescriptions for the gout, (neither worked), and one for pain. It didn’t work either. Tuesday I got back to my doctor, and he again fixed me up in a week or so, (even though the gout had traveled to my knee.)

    I eventually settled with the ER doctors for about $430.00[3] I still have an overdue bill for ER services for $966.00 sitting here on my desk. I haven’t decided if I will protest on the basis of malpractice, or offer to settle for 1/3, since it is common knowledge E-rooms triple the charges from the git-go, because they know the insurance companies will chisel them down. They hospital never billed me as the doctors did; they just sent a statement to a collection agency. I checked out their website, and I feel honored such a stellar organization would deign to write to me.

    I also missed three weeks of work. This is not an unusual horror story; it is simply ordinary, daily healthcare in America for the working class slob.

    11/20/2005 frog405

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  14. Finally:

    Footnotes:

    [1] I told my doctor that Vioxx was quite controversial in the US, and he said not to worry, that the ado was simply competition between two American drug companies.

    About two months later, I read in the Paris Herald Tribune that the FDA was going to pull Voixx off the market pending a lawsuit. I went to renew my prescriptions the next day, and when the pharmacist called up my account, he told me that Vioxx was no longer available. He called my doctor, who switched the prescription to Celebrex.

    When I went to renew the Celebrex, the pharmacist asked me how well it worked. I told him that Vioxx was a very effective analgesic, but that Celebrex seemed to have no pain-killing properties whatsoever. He asked me if I wanted to renew the prescription, and I declined.

    [2] These procedures were virtually identical to those offered in the US. US prices were $40.00 co-pay per visit!

    [3] My US insurance for me alone cost me $140.00 per month. It had a $500.00 deductible, and I used that up for my prescriptions for 3 months. My insurance, which was from work, was considered pretty good, except it had no emergency room coverage.

    [On one ER visit, I received 5 sutures. The suture kit alone, which consisted of a needle and sutures, some saline solution, and some gauze, was charged out at $100.00!]


    UPDATE 8/09/2009:

    Today, Assurance Maladie covers about 88% of France's population of 65 million. The remaining 12%, mainly farmers and shop owners, get coverage through other mandatory insurance plans, some of which are heavily government-subsidized. About 90% of the population subscribes to supplemental private health-care plans.

    In 2004, France introduced a system under which patients must select a "preferred" general practitioner who then sends them onward to specialists when necessary. Under that policy -- similar to one used by many private U.S. health-care plans -- France's national health insurance reimburses only 30% of the bill, instead of the standard 70%, if patients consult a doctor other than the one they chose. - Wall Street Journal 8/07/2009

    CMU contributions can now only be paid by French nationals or long-term residents of five years or more, or non-nationals who were already resident in France and affiliated to the CMU at 23 November 2007. All others now must insure privately for healthcare.


    Posted by gravymeister at 1:25 PM 0 comments Links to this post

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  15. The limit on content caused this to be out of order.

    This is part one of French healthcare.
    Sorry!

    Saturday, August 1, 2009
    Eyewitness Report - French Healthcare
    I am re-writing this in response to some patently false statements about European healthcare made in the past and recently by Sens. John McCain and Jon Kyl, and Reps. Jeff Flake and John Shadegg. (I currently reside in Arizona).

    The Process

    My wife and I lived in France as legal residents from June 2002 to April 2005. The collapse of the US dollar forced us to move back to the US.

    We were required by law to sign up for French medical insurance even before we received our official French ID card. We were ordered to a clinic in Avignon, where we were interviewed for a few minutes by a harried doctor, and then were sent to his radiologist for chest X-rays. It was obvious that the only concern was TB or some clearly visible communicable disease. The exam was free, but the subsequent French ID cards were about €500 for both of us. The French ID card (Carte de Sejour) was not the health insurance card, but a picture ID indicating that we were legal residents of France.

    The French healthcare card (Carte Vitale) was a smart card that carried information in an EPROM. Medical insurance cost about €100 per month ($90.00) for both of us.

    Here’s how it worked. When you wanted to see a doctor, you went to his or her office, sat in a waiting room with anywhere from three to a dozen others, and waited, first come first serve, until you got to see the doctor. No one was turned away. There were no receptionists, file clerks, insurance claim clerks, nurses, or assistants. There was only the doctor.

    You would tell the doctor your symptoms; he would examine you, ask a few questions, make a diagnosis, and give you a prescription. If lab work was needed, you would go to the nearest lab and, same thing, no appointment needed. When the lab got the results, they would notify you, and send the results to your doctor. There was no charge for lab work.

    At the end of the doctor’s visit, he would take your healthcare card and put it into his laptop for a few seconds. You would then give him €20 cash, and leave. A few days later, €14 would be deposited to your bank account by the healthcare system.

    We had to renew or coverage each year, and as the dollar fell, and our real income with it, our insurance premiums also went down.

    Medication

    At the pharmacy, you would give the pharmacist your healthcare card and you scripts. He would call up your account on his computer, and enter the prescription information. 75% of the price was paid by the healthcare system, (it changed to 70% while we were there), and we paid the balance.

    Drug prices were cheaper than in the US. Generics were about the same, but brand names were considerably cheaper.

    Full Coverage

    Anyone paying into the system could opt for private top-off medical insurance, which would result in full reimbursement for all medical expenses.


    A Dutch friend of ours who had top-off insurance went to her doctor with severe headaches. She was diagnosed with a brain tumor, and told to go to a hospital in Lyon, France’s second largest city, and about 5 hours away by car. Her husband drove there that day. She was admitted to the hospital, had surgery the next day, and after a week she was released. Charges? 0. And I mean no money paid out at all.

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  16. My husband and I are self employed. We both had the misfortune to work for companies who went bankrupt and/or moved operations out of the US.

    We pay $1950 a month for health insurance in New Jersey. He will be on Medicare January 1 - hurray! BTW he runs 3 miles at a clip and I am a yoga instructor - both of us are blessed with good health.

    Health insurance has broken our backs and has had a negative impact on our savings. But who could be without it?

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  17. "But, many jobs pay a lot more here than overseas. E.g., auto workers, university administrators, university faculty, government employees, postal employees, truckers, railroad workers, and most other Americans earn a lot more than their overseas counterparts. "

    Is that right? Wow, I had no idea middle-class Americans were so overpaid. Does DoC by chance have some links to international wage comparisons which support this generalization? Thanks in advance.

    " I would guess that such a comparison would show that the over-65 Americans spend more, relative to our foreign counterparts, than the under-65 group. The reason I think so is the enormous increase in my own medical spending since I've been on Medicare. I find myself making greater use of medical practitioners."

    Maybe DoC could find out whether his guess is correct and get back with us. No doubt he finds himself making greater use of medical practitioners now that he is retired; this is an expected consequence of aging.

    ReplyDelete
  18. Sorry, Anon. I don't have those stats. I did find average wage by country at http://en.wikipedia.org/wiki/List_of_countries_by_average_wage

    US wages are the highest, but I was surprised to find many European countries fairly close to the US (although Japan is quite a bit below.) I must admit this table makes me reconsider my guess about how much more American workers are paid than overseas counterparts.

    ReplyDelete
  19. Thomson Reuters issues a healthcare report each year that is very helpful to see where some of the money goes. Per them, we could save $260 billion per year just from single payer which would eliminate the 30% in insurance administrative overhead and profit.
    Waste, fraud and abuse in Medicare, Medicaid and similar programs cost billions more which single payer would also help reduce. Single payer is short hand for better but it may not mean the elimination of private insurance. See France, Switzwerland, Germany etc.
    The Kaiser Foundation is another good source of data.

    David in Cal is not a good source, neither is the Wiki albeit a better place to start.

    ReplyDelete
  20. Average wage stats are not useful, David in Cal, because the US has a large wage gap between the highest and lowest paid workers and the highest paid workers in the US make far more than their counterparts in Japan and Europe, a fact I suspect you already know but chose to overlook:

    "CEOs at Japan's top 100 companies by market capitalization earned an average of around $1.5 million, compared with $13.3 million for American CEOs and $6.6 million for European chief execs at companies with revenues of higher than $10 billion, according to an analysis of 2004-06 data by Towers Perrin, a Stamford (Conn.) human resources firm. "

    http://www.businessweek.com/globalbiz/content/feb2009/gb20090210_949408.htm

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  21. "I might add that all this medical care is making me healthier. However, most of the benefit goes to improving my quality of life, rather than extending my life.

    ...

    My personal experience suggests that simply comparing average life spans isn't that good a way to compare medical effectiveness. "


    You might be interested in this study comparing not only life expectancy but the number of years lived without serious disability or impairment. Needless to say, the US is nowhere near the top. The data are from 2001, but there's no reason why rankings should have changed dramatically in the past ten years:

    http://www.nationmaster.com/graph/hea_lif_exp_hea_yea-health-life-expectancy-healthy-years

    ReplyDelete
  22. As far as wages in France go, the average workers make about $20 Euros per hour, after healthcare premiums are deducted from their wages, as is a retirement guarantee equal to their working standard of living.
    in addition they get 11 paid holidays and 5 weeks paid vacation per year
    If they are laid off, they get unemployment that is equivalent to their wages for a period ranging from 122 days to 730 days, and women get 16 weeks paid maternity leave, (26 for the third child).
    I'd like to know what Rank and File American gets anything close to this.
    It should be noted that taxes are much higher in France than the US. Something the Tea Partiers might like to look into. We Americans get what we pay for, and, apparently, so do the French.

    ReplyDelete
  23. David in Cal - I suggest that you look at the rate Americans overpay supervisors and executives. The pay rates are far above their economic contribution to the goods and services their institutions provide. And American auto workers are paid less per hour than those in Germany or Japan. It's a fantasy to believe that "...most other Americans earn a lot more than their overseas counterparts." Yes, the American system of management and ownership is looting the people.

    Besides the looting of the system by managers and capitalists, there is the excessive cost associated with each damned insurance system having its own administration system. They duplicate the same functions but do it in different ways so that health care providers are locked into a few networks or insurance companies. It is estimated that a quarter or more of a physician's time is spent arguing with insurance companies over treatments to be paid for. In addition, there are 2 1/2 clerks supporting each physician in the process of performing administration. A single standardized national system of administration would require between 1/2 and 1 clerk per phyician, the physicians would not have to learn a different set of rules for payment from each insurance company and the standards of payment would be the same if there were a universal national appeal system together with a national set of standards of care. These are just a couple of the many inefficiencies that are built into the free market unregulated lack-of-system of providing health care.

    Also David, you confuse the process of paying for medical care with the process of delivering medical care. Compare the cost of medical care the government actually delivers (such as the VA) to that which it merely pays for on the economy and the government care will be less expensive and often more effective.

    Finally, if you have any mathematical training you will recognize that your personal experience by itself cannot be reliably compared to group statistics such as averages. All you are saying is that you have no idea what is happening to others in society. Your comment is based on unsupported personal bias, not on repeatable facts.

    ReplyDelete
  24. Want another reason why American health care costs more? I tried out a new dentist several years ago. She was close and took my dental insurance.

    Strangely, each time I visited her I needed two fillings in addition to the items covered under my insurance. The third time it bothered me that the fillings were in the generally same location (hard to tell from the chair, though.) The problem is that I hadn't needed a filling in over twenty years before seeing her. But she could charge me cash for the fillings. The other work was fully covered.

    I have no doubt she was padding the bill and I suspect - hope - she was faking the work. If she was not faking it she may have damaged teeth.

    ReplyDelete
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