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Increase the Supply

There's one criticism that nobody from either party is making of the Obama/Pelosi health care plan, not the Republicans, and not the Blue Dog corporate Democrats, either, and it would, ironically, be a fair complaint. You see a teensy little hint of it in the oft-heard argument about whether or not there's anything in the plan that would actually reduce costs. That's important, because if we increase the customer base by increasing eligibility, but we don't reduce the cost, then the total cost of healthcare just plain has to go up. Period. But so far, that argument has taken the form of arguing about whether or not preventative medicine saves lifetime costs (and contrary to what Obama and Pelosi would have you believe, experiments in this area have not been conclusive), arguing about just how many dollars can be saved by upgrading and standardizing billing and patient records systems. What's missing from that argument is the single most obvious question: why does it cost so much in the first place?

And, frankly, if there weren't a massive political taboo about answering that question, if the answer to that question weren't deeply Forbidden Lore and completely off-limits in polite company, the answer would be quite obvious, because it's the same answer as every other time you ask the question about why any other fill-in-the-blank is so expensive: demand is high, supply is low. Well, then, you ask whenever demand is high and supply is low, why is the supply so low? Here's what nobody, from either political party, has the guts to say to you: because the dominant cost in the health care industry is set by two of the most untouchable, politically powerful price-fixing cartels, the two most corrupt unions in the entire country: the American Medical Association and the American Dental Association. Even the similarly collusive and equally greedy price-fixing cartel that is made up of the tiny number of CEOs of pharmaceutical companies lives in awe of the clout, and the brazenness, of the AMA and the ADA.

Here is what nobody has the guts to tell you, for fear of what would happen to them if they did. Back in the 1970s, the ADA and the AMA decided that there was something morally wrong about having doctors and dentists earn a middle class salary. And, they concluded quite rightly, there was a reason why attempts to price-fix the salaries of doctors and dentists weren't working: there were just too many doctors, and far too many dentists. The barriers to entry to the field were too low. So what they did about it was adopt a political position of absolute and total opposition to any expansion of medical schools or dental schools. In 1970, the US population was 203 million. Now, the US population is 309 million, slightly more than 1.5 times as high ... but thanks to the unceasing efforts of the ADA and the AMA, we graduate the same number of doctors and dentists per year that we did back in 1970.

They say that if they didn't restrict the number of classroom openings in medical school, too many unqualified people would become doctors. But the number of medical scandals hasn't declined as admissions standards have climbed, as medical schools mobbed with 50% more applicants per seat than they had in 1970 get to be more picky. No, on the contrary, even with the tougher admissions standards we have today, you can be entirely qualified to enter medical school, you can demonstrate through your grades and your test scores in pre-med that you are entirely capable of becoming a doctor ... and get turned away, in favor of someone more qualified. But saying it that way doesn't change the fact that you were still perfectly qualified to be a doctor, and would have made a perfectly good doctor, as good as any doctor that's graduating today, and maybe even better than some, but you won't be; at best, you'll be a nurse practitioner, or a medical technician.

Confronted with this ... which they almost never are ... the medical associations would argue that we must restrict the supply of doctors per capita, of dentists per capita, because if neurosurgeons couldn't look forward to a salary of $950,000 per year or more, nobody would want to become a neurosurgeon, because if dentists couldn't look forward to a salary of $175,000 per year or more, nobody would be willing to become a dentist. (And yes, those numbers are after operating expenses, including malpractice insurance, and long after the medical school loans are paid off.) They insist, contrary to all evidence, that there is nobody who'd be perfectly willing to save lives for, say, $500,000 per year, that nobody would be willing to repair teeth for a measly $90,000 per year. Which is deranged, or else they wouldn't have to be stopping people from trying to do so, so they can support those salaries! Nor can they erase the historical evidence that, back when medical schools and dental schools were expanding as the US population expanded, there were in fact no shortage of perfectly happy, perfectly comfortable middle-class dentists and upper-middle-class surgeons; indeed, the great advances in heart repair and transplant surgery were made by surgeons who made a great deal less than today's doctors do.

Greg Mankiw, the tireless (and tiresome) supply side economist, recently blogged that all the proof he needed of how the superior American health care system is the best in the world can be found in two readily available facts. First of all, he pointed out, American doctors must be the best in the world, or else they wouldn't be getting paid twice as much! And secondly, if American doctors weren't the best in the world, we wouldn't be able to deliver the quality of health care we do with half as many doctors per capita as every other industrialized nation! This tells you all you need to know about the intellectual rigor behind supply-side economics: the man who literally wrote the standard textbook on Chicago-School economics (a) thinks that American health outcomes are as good as the rest of the industrialized world, when our actual statistical outcomes are closer to third-world levels, and (b) he isn't enough of an economist to realize that the reason doctors doubled their salaries, relative to inflation, isn't because they became twice as good, but because (as he himself knows) they became twice as scarce.

When I was a kid in the 1970s, as (arguably) one of the very last of the Baby Boomers, I was told that part of the promise of America was that no matter what color you are, what gender you are, what neighborhood you were born in, or what your parent(s) did for a living, if you did the work, if you learned the material, if you proved that you were good enough, there was nothing you couldn't do. And maybe, in the 1970s, that was almost sort of true, or at least more so if you were white and male. But in the intervening time, we allowed powerful price-fixing cartels to set quotas for just how many people, regardless of whether or not they did the work, regardless of whether or not they learned the material, no matter how good they proved they were, would be allowed to become doctors or dentists. Once those quotas are filled, ideally with privileged children of the upper-middle class, everybody else who was capable of being a doctor gets shunted back down to become a nurse practitioner, a physician's aide, a medical technician. Once those quotas are filled, ideally with the somewhat privileged children of the middle class, everybody else who was capable of becoming a dentist gets shunted back down to become a dental assistant, a dental technician, a dental hygienist. In other words, only half of our qualified people are allowed the artificially scarce privilege of being real doctors or real dentists, so that the person working on the $15,000 a year telemarketer's teeth can be guaranteed a salary ten times as high, so that the person stitching the replacement veins onto a $90,000 a year computer programmer's heart can be guaranteed a salary ten times as high. All of the missing doctors and missing dentists who might have done it for half as much (and still lived quite comfortable lives!) must, instead, serve as the barely-working-class, chronically emotionally abused servant class of the doctors and dentists.

I don't care if we import enough doctors and dentists from overseas to double their numbers. (I had the good fortune to have my dentist before-last be a Russian Cold-War refugee, and don't let anybody tell you that there are no med schools as good as ours; she was a better dentist than almost any other dentist I've ever had work on my teeth.) I don't care if we do it the more reliable, and maybe safer, and certainly less internationally politically explosive way by doubling the number of medical and dental school classrooms, even if we have to temporarily import doctors and dentists to teach in them. All I know is this: whenever anybody, any politician or spokesman or journalist or think-tank intellectual or author, from either party, either pro-reform or anti-reform, talks about health care, the question you ought to be asking them the first is: "what do you plan to do to increase the amount of health care available in the United States?" Because you can't solve even the tiniest of the problems with health care costs, let alone the main problem, if you don't increase the supply. That's just basic economics.

Comments

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crasch
Jul. 24th, 2009 04:23 pm (UTC)
Here's what nobody, from either political party, has the guts to say to you: because the dominant cost in the health care industry is set by two of the most untouchable, politically powerful price-fixing cartels, the two most corrupt unions in the entire country: the American Medical Association and the American Dental Association.

You're right that you won't hear about it from the Democrats or Republicans. But it's not exactly Forbidden Lore.

The Medical Monopoly: Protecting Consumers or Limiting Competition?
http://www.cato.org/pub_display.php?pub_id=1105&full=1

Medical Licensing: An Obstacle to Affordable, Quality Care
http://www.cato.org/pub_display.php?pub_id=9640

Medical Licensure (Milton Friedman, 1994)
http://www.fff.org/freedom/0194e.asp

professor
Jul. 24th, 2009 04:56 pm (UTC)
Ok, thank you for writing this. I haven't even read the whole thing yet. But just last night, I was wondering to myself, "Why are medical costs so high in the first place? Why do doctors have such high salaries? Why does medical school cost so much money, that (some) doctors almost NEED those high salaries just to pay their loans?" And then this morning I see that you wrote this. So, thank you.
rowyn
Jul. 24th, 2009 05:10 pm (UTC)
Are nurse practitioners too cheap?
I got strep throat on Tuesday, and went to a Take Care clinic on Wednesday for treatment. I spent about 15-20 minutes with a nurse, and 20-30 minutes with a nurse practioner. The retail cost of my walk-in visit was $80. The actual cost was discounted down to $34 -- not because my insurance was covering the rest, but because of an arrangement my employer has with the Take Care chain.

Now, $80 for 40 minutes' worth of time, plus the cost of test materials, from medical professionals doesn't seem unreasonable to me. It's in line with what I'd expect to pay other experts for services -- a massage therapist, for example, or a plumber. $34 is awfully cheap, but presumably my company is paying for that discount.

I went to a clinic because my primary care physician was booked through September.

I'm not sure where I'm going with this, except to that yeah, you're right, our supply chain for doctors is all screwed up.
kimchalister
Jul. 26th, 2009 04:20 am (UTC)
Re: Are nurse practitioners too cheap?
Is that picture you?
Re: Are nurse practitioners too cheap? - rowyn - Jul. 26th, 2009 12:04 pm (UTC) - Expand
Re: Are nurse practitioners too cheap? - kimchalister - Jul. 27th, 2009 10:27 pm (UTC) - Expand
Re: Are nurse practitioners too cheap? - rowyn - Jul. 27th, 2009 10:31 pm (UTC) - Expand
Re: Are nurse practitioners too cheap? - dglenn - Jul. 27th, 2009 06:27 pm (UTC) - Expand
Re: Are nurse practitioners too cheap? - rowyn - Jul. 27th, 2009 07:22 pm (UTC) - Expand
kallisti
Jul. 24th, 2009 05:31 pm (UTC)
Many Canadian doctors go to the States, and then return to Canada after about 5-10 years of practice...my current doctor did so, and a lot of the reason he came back was the insanity of doing their billing. Although there is a standard (x11, if I remember correctly) for electronic billing of the insurance companies, they are all subtly different in the wording of different diagnosis, reasons for prescribing a certain drug, etc...So doctors and their office workers end up spending lots of time filling out claim forms so that their patients get what the doctor feels they need, rather than what the insurance company thinks they should get.

I got to see this first had as I made the operating system that was used for a small player in the medical office management software field...the person who did the billing/claims module literally went crazy!

ttyl
atomicat
Jul. 28th, 2009 03:42 am (UTC)
Wait wait wait, hold on! Now I've been told by well, everyone, that they will be getting bureaucrats who's full-time jobs it will be to limit how much health-care they're worth! So isn't that a plus, them having to do that rather than the doctors? We could use some of those people up here in Canada y'know, cos they've been busting their sorry asses to save my sorry ass and somebody really should put a stop to it! *eye-roll*

Truly astounding how many people would rather believe bullshit horror-story propaganda put out by those who don't want change rather than the people who've lived with this system our entire lives. I wonder when I first applied for my Manitoba Medical card, no idea, but it would of course be the only medical related form I've ever filled out in my entire life.
(no subject) - kallisti - Jul. 28th, 2009 04:09 am (UTC) - Expand
(no subject) - atomicat - Jul. 28th, 2009 05:16 am (UTC) - Expand
(no subject) - kallisti - Jul. 28th, 2009 01:44 pm (UTC) - Expand
phillipalden
Jul. 24th, 2009 07:01 pm (UTC)
My father-in-law (FIL) is a semi-retired Radiologist. Through years of hard work and practice building he's done pretty good for himself.

But he gets these free magazines from health insurance companies that get sent only to doctors. These rags are filled with scare stories about how broke doctors will be if we have universal health care, and what a disaster it would be for the medical industry.

It's propaganda, pure and simple, but doctors are generally very busy people, so many must swallow this bullshit without thought.

They're trying to scare doctors so they will oppose change.
samael7
Jul. 24th, 2009 07:29 pm (UTC)
I'm glad you brought this up, Brad. I'd seen this endorsed elsewhere by folks with varying credentials to speak on the matter. It's been floating around my head, and I had a question about it, but I'm not sure it's a "good" question, and I'm rather glad that, heated though your livejournal may occsaionally become, I have a place where I can air a thought in a forum that would at least respect that I'm not deliberately trying to be a douchebag.

Insofar as the AMA is keeping the supply of doctors artifically low to line their members' pockets, I understand why breaking through that is necessary to controlling costs.

But I wonder what would happen in actual practice, given that medical groups (which, perhaps themselves arise from this supply-limiting) are also determined to maximize profits by maximizing a provider's daily load. Is there not an incentive for medical groups and hospitals to control hiring, regardless of supply, to maximize revenue from the doctors they have?

Now I realize that adding more doctors to staff would mean an increased patient load and customer base. And, along with this, an increase in doctor supply should (eventually) deflate the cost of hiring and retaining providers. So perhaps that answers my own question, but for some reason, I can't stop thinking about what it would "really" mean for there to suddenly be an abundance of providers on the market.

Would existing providers, with their artifically inflated salary, take a cut in pay voluntarily? Or even involuntarily? Would we simply have to wait for attrition for those proviers to retire or move on? How discouraging would this be to the field for newcomers to see old-timers 15-30 years in practice suddenly be making less money? How do education costs figure into this, since that's a very long, costly road in and of itself?

Or perhaps providers would move away from group practices into their own practice, although given the way aspects of medicine have set the stage for the rise of specialists, there seems to be more interdependence between GPs and specialists than in times past. Plus malpractice insurance costs are more easily shared amongst a pool, right?

It's funny. I've worked in Hospital IT tech for 15 years, and like Kallisti above, I've seen iterations of Byzantine billing requirements, restructuring of fee schedules, contracted reimbursement, bundling/unbundling, and the eternal cat-and-mouse game that payors and providers (or at least their billing agents) have to play, with the former wanting to dole out as little as possible, and the latter eager to get the maximum possible for procedures. And, yes, it will drive you bonkers if you're not careful. So I'm aware of how those kind of cost controls impact healthcare too.

The AMA's role, whatever it might be, in this is somewhat new to me (given that I've technically worked for doctors, I shouldn't be surprised), and what I'm hearing from you and others seems logical and obvious. But are the consequences what we think they are going to be? (I'm fine with "yes," but it'd be nice to have some of my thoughts above resolved or dismissed on the basis of an incorrect assumption)
bradhicks
Jul. 24th, 2009 07:48 pm (UTC)
Well, doubling the number of med-school seats certainly can't be the only thing we do. But it would be a necessary part to actually getting anything done on anything else. For example, you mention hospitals. Where I live, various government agencies have deliberately shut down somewhere around a quarter of the hospitals that were here when I was a kid, even though at least two of them, Normandy and Phillips, were quite busy. They were closed because other hospitals were complaining that they were facing too much competition.

Basically, part of where I'm leading with this is that nothing in the current status quo (which, the President quite rightly pointed ou the other night, is not merely unacceptable, it's unsustainable, unaffordable) nor anything in the Obama/Pelosi plan does anything about increasing the supply to meet the demand, and basic economics says that that's the only way to sustainably bring down the price of anything.
hairyfigment
Jul. 24th, 2009 09:17 pm (UTC)
I don't know if he specifically says it in connection with this plan, but liberal economist Dean Baker has argued for years* that we should allow qualified people from other countries to practice medicine in the US. This still appears on the front page of his blog.

*When not harping on his dogmatic belief in the existence of a "housing bubble".
kimchalister
Jul. 24th, 2009 09:49 pm (UTC)
That's important, because if we increase the customer base by increasing eligibility, but we don't reduce the cost, then the total cost of healthcare just plain has to go up.
Except if we pay directly, via a “single-payer” system, we cut out the 30% or so that goes as profit to the insurance industry.

Nor can they erase the historical evidence that, back when medical schools and dental schools were expanding as the US population expanded, there were in fact no shortage of perfectly happy, perfectly comfortable middle-class dentists and upper-middle-class surgeons; indeed, the great advances in heart repair and transplant surgery were made by surgeons who made a great deal less than today's doctors do.

One more result of this is that it encourages students who are in it for the money rather than because they have a passion for health care. And we have seen that in the industry.

All of the missing doctors and missing dentists who might have done it for half as much (and still lived quite comfortable lives!) must, instead, serve as the barely-working-class, chronically emotionally abused servant class of the doctors and dentists.

Remember your article:
http://bradhicks.livejournal.com/270725.html
Some 12 Year Olds Can Reinvent Seventy Years of History in a Day
? This is an instance of the winners of one round making the rules for the next round.
jsl32
Jul. 27th, 2009 01:29 pm (UTC)
source for the 30% profit figure?
actual profit margins are generally like 3-5%, with a lot of earnings spent in advertising and administration.

i don't actually want there to be insurance companies, but i'm not going to claim they make 30% profits, either.

Re: source for the 30% profit figure? - kimchalister - Jul. 27th, 2009 10:23 pm (UTC) - Expand
Re: source for the 30% profit figure? - jsl32 - Jul. 28th, 2009 06:46 am (UTC) - Expand
Re: source for the 30% profit figure? - kimchalister - Jul. 28th, 2009 07:23 pm (UTC) - Expand
Re: source for the 30% profit figure? - jsl32 - Aug. 4th, 2009 12:25 am (UTC) - Expand
Re: source for the 30% profit figure? - kimchalister - Aug. 4th, 2009 03:21 am (UTC) - Expand
Re: source for the 30% profit figure? - jsl32 - Aug. 9th, 2009 12:17 pm (UTC) - Expand
txtriffidranch
Jul. 24th, 2009 11:23 pm (UTC)
And you want the cherry on the top of that dog shit sundae? There's a very good reason why the IRS now garnishees the income tax refunds of those who default on their student loans. (Or their spouses, as I discovered a decade ago when my ex-wife decided that she didn't have to pay the rest of her student loan "because the bill collectors stopped calling" and the IRS took my refund check for the next two years.) The reason why was due to the number of high-earners who felt that they didn't need to pay back their loans because "I didn't get anything out of my time in school." The number one group in that default category? Doctors and dentists.
alithefiend
Jul. 25th, 2009 12:36 am (UTC)
As second year medical student, I sincerely disagree with your argument. The fundamental flaw in your argument is that you place the blame on the healthcare system as it is today the doctors and the organizations that regulate them.

You neglect to examine the insurance system and their role in regulating doctor wages, (point one, primary care doctors are reimbursed less by insurance companies per their time spent than specialized doctors for their procedures). The difference between remaining in primary care and becoming a specialized doctor is a test score and 1-4 more years of residency. Everyone needs a primary care doctor, not everyone needs a dermatologist. This overall trend has lessened the percentage of those going into family practice and other fields, and that is where your poorer communities are strained.

The AMA/ADA do not control the entire U.S. healthcare system. One word for you, osteopath. Osteopathic medicine has been growing at a large rate, with many new schools opening every few years and aiming to increase the number of doctors, particularly in the more needy fields of medicine. In addition, you have nurses, medical assistants, and even dental hygienists with less training taking over more of the more rudimentary physician duties to free up time for the doctor to fulfill his role as more of a decision-maker.

Your average doctor salaries are between 150K and 350K. Yes, neurosurgeons make around a million dollars but you are misleading people into thinking doctors make statistically more than lawyers or other professionals. But, if you want us to play that game, a neurosurgeon requires 14 years of education and training AFTER college. This length of time is what makes the profession less glamorous, and indeed, neurosurgery isn't nearly the most competitive specialty to get accepted to. Your radiologist scored higher on his USMLE than your neurosurgeon.

You ignored the pharmaceutical companies' role in increasing the cost of healthcare, these are not non-profit businesses. Then again researching and testing drugs is an extremely expensive process, and that cost is passed more to the consumer. People are paying more for medicines that didn't exist 5-10 years ago.

You ignored hospitals and their business strategies having any effect on the cost of healthcare. They charge more for their rooms than a 5-star hotel, but this is a non-concern.

You also ignored the severity of malpractice lawsuits. Malpractice rates rise at a much greater percent than physician salaries do, the minimum doctors pay for insurance is around ten thousand, and the highest are in surgical fields and especially ob-gyn who pay around $100,000 annually. This is particularly bad in certain states like Florida, where pregnant women are having a hard time finding a doctor to deliver their baby. Gynecologists have been leaving the OB out of their practice, cause the extra insurance is costing them more than they earn.

But really, this is as far as I'm going to go. I could find some statistics to show you maybe that these doctors earn salaries which they work 50-70 hours a week for, or perhaps a statistic on how much time it takes to pay off student debt for a newly graduating doctor, maybe a thought on how much we make during our residencies when we work the maximum lawful time a doctor can work in a week for years with the hope that one day we can live comfortably for sacrificing over a decade of our lives to enter this challenging profession.

But I love helping people right? It's ok though, I'll just go work in a country where I have a more comfortable life. I'll be glad to work only 40 hours a week and be paid as much as working 70 hours, and that's the direction you are going with this.
hairyfigment
Jul. 25th, 2009 02:08 am (UTC)
Well, I mentioned Dean Baker just now. He makes a lot of these points (including the need for public health insurance, of course) but also says we currently have protectionist policies to increase the pay of many kinds of professionals.
(no subject) - kimchalister - Jul. 25th, 2009 04:42 am (UTC) - Expand
(no subject) - bradhicks - Jul. 25th, 2009 09:09 am (UTC) - Expand
(no subject) - alithefiend - Jul. 25th, 2009 04:00 pm (UTC) - Expand
(no subject) - bradhicks - Jul. 25th, 2009 11:10 pm (UTC) - Expand
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amberite
Jul. 25th, 2009 07:44 am (UTC)
There's a great deal of up-fuckage in the system, and if I decide not to become a doctor, it will be because of that up-fuckage. It will be because too many hospitals do not have checklists, and do not encourage speaking up about errors; it will be because the compensation during residency is not always enough to pay off student loans and still support the cost of living; it will be because the amount of corruption, in short, that people on all sides of the system are expected to deal with on a daily basis, is plain fucking crazy.

I've realized, reading up on the issues, that in fact if the salaries of doctors are lowered without unbreaking the rest of it, doctors may indeed have trouble paying their loans and malpractice premiums. And that is because the system is fucked throughout. Any attempt to fix one aspect of it without fixing the rest is going to go over like a lead balloon.

Opening more med schools would help. Reducing intern/resident hours would help. Changing, as Atul Gawande suggests, the malpractice insurance system to a litigation-free public fund system like the one that currently benefits people who suffer side effects of vaccination would help.
bradhicks
Jul. 25th, 2009 02:14 pm (UTC)
Right. One of the biggest reasons why we've known we had this problem since the 1940s and nobody's done anything about it yet is that the American people have normally-justified fear of complete overhaul, a normally-justified strong preference for incremental reform. But this is not something we can incrementally reform our way out of, I'm pretty sure.
(no subject) - amberite - Jul. 25th, 2009 11:08 pm (UTC) - Expand
murstein
Jul. 28th, 2009 01:20 am (UTC)
You know, I was all set to use the points you bring up . . . until I discovered they don't quite agree with the facts. Such as the fact that the population of physicians practicing in the US has grown from 340,280 in 1975 to 762,438 in 2005. (For the statistics, see Table 110 on Page 411 of this file.) Over the same period, the US population grew from 215,973,199 in 1975 to 295,560,549 in 2005.

Applying a calculator to those numbers, I see that there was one physician in practice for every 635 Americans in 1975, but one physician for every 388 Americans in 2005.

Picking 1975 as my start date for no reason other than that's when I found my number-of-practicing-doctors figure, I checked your assertion that no medical schools had opened since the 1970s. My findings, sorted by year of foundation, are:

1975 (OK, maybe the ban started later?)

1975 (Technically a restart, but I think the lack of graduates between 1827 and 1975 makes it feel like a new school.)

1976 (Does this not count because Puerto Rico voted against becoming the 51st State?)

1977

1977 again

1977

1978

1979

1980

1992

2000

2002

2005

2006

2006 again!

2007.

2009

I'm afraid this appears to destroy your restraint-of-market argument. Not only have we grown the population of doctors faster than the population as a whole, but a simple check of Wikipedia finds that 13% of the medical schools presently operating in the US were opened in, or after, 1975.

Places where you might rebuild a portion of your point:

* The gap in schools founded between 1980 and 1992.

* Dividing the number of medical schools in the US by the number of years since we declared Independence suggests we should have founded 19 in the period, instead of the 17 we actually founded.
(Anonymous)
Aug. 5th, 2009 05:24 am (UTC)
Hmmm...
Any answer to this, Brad? If it's true, it kinda demolishes the post...
livejournal
Jun. 28th, 2012 07:18 pm (UTC)
Cryotheraphy.
User landley referenced to your post from Cryotheraphy. saying: [...] cartels [...]
livejournal
Jan. 26th, 2013 09:09 pm (UTC)
Education, For The Masses and The Classes
User peristaltor referenced to your post from Education, For The Masses and The Classes saying: [...] well as previous professionals. Some cartels worked to restrict the supply of future professionals [...]
livejournal
Jan. 26th, 2013 09:18 pm (UTC)
Education, For The Masses and The Classes
User peristaltor referenced to your post from Education, For The Masses and The Classes saying: [...] well as previous professionals. Some cartels worked to restrict the supply of future professionals [...]
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