Medical Tourism: Global Competition in Health Care

Studies | Health | International

No. 304
Thursday, November 01, 2007
by Devon M. Herrick


Notes

  1. McKinsey & Company and the Confederation of Indian Industry, cited in Laura Moser, “The Medical Tourist,” Slate , December 6, 2005, and Bruce Stokes, “Bedside India,” National Journal , May 5, 2007.
  2. See Dudley Althaus, “More Americans Seeking Foreign Health Care Services,” Houston Chronicle , September 4, 2007.
  3. McKinsey & Company and the Confederation of Indian Industry, cited in Laura Moser, “The Medical Tourist,” and Bruce Stokes, “Bedside India.”
  4. Mark Roth, “$12 for a Half Day of Massage for Back Pain,” Pittsburgh Post-Gazette, September 10, 2006.
  5. McKinsey and the Confederation of Indian Industry, Press Trust of India, 2005.
  6. Joshua Kurlantzick, “Sometimes, Sightseeing Is a Look at Your X-Rays,” New York Times , May 20, 2007.
  7. “Medical Tourism Growing Worldwide,” U Daily (University of Delaware), July 25, 2005.  Available at http://www.udel.edu/PR/UDaily/2005/mar/tourism072505.html.  Accessed May 22, 2007.
  8. Malathy Iyer, “India Out to Heal the World,” Times of India, October 26, 2004.
  9. Jessica Fraser, “Employers Increasingly Tapping Medical Tourism for Cost Savings,” News Target , November 6, 2006.
  10. “Who Can Have Fertility Treatment?” BBC Health, undated.  Available at http://www.bbc.co.uk/health/fertility/features_whocan.shtml.  Accessed April 30, 2007.  Also see “Cost of Fertility Treatment,” 2006. Available at http://www.gettingpregnant.co.uk/cost_information.html. Accessed April 30, 2007.
  11. Arnold Milstein and Mark Smith, “Will the Surgical World Become Flat?” Health Affairs , Vol. 26, No. 1, January/February 2007, pages 137-41.
  12. Arnold Milstein and Mark Smith, “America's New Refugees — Seeking Affordable Surgery Offshore,” New England Journal of Medicine , Vol. 355, No. 16, October 19, 2006.
  13. Neal Conan (host), “Outsourcing Surgery,” National Public Radio, Talk of the Nation, March 8, 2007. Available at http://www.npr.org/blogs/talk/2007/03/outsourcing_surgery.html.  Accessed April 13, 2007.
  14. Diana M. Ernst, “Medical Tourism: Why Americans Take Medical Vacations Abroad,” Pacific Research Institute, Health Policy Prescriptions, Vol. 4, No. 9, September 2006.
  15. Beverly Blair Harzog, “Medical Tourism Offers Healthy Savings,” Bankrate.com, March 23, 2007.
  16. “Point of View: Eastern Europe,” HealthAbroad.net. Available at http://healthabroad.net/blog/?cat=8. Access verified June 22, 2007.
  17. Although many Americans patronize Mexican physicians, it is most common for seniors to cross the border for cheaper drugs, opticians and dentists. See Milan Korcok, “Cheap Prescription Drugs Creating New Brand of U.S. Tourist in Canada, Mexico,” Canadian Association Medical Journal , Vol. 162, No. 13, June 27, 2000; Steven Gluck “Bargain Dentistry — Wooden Teeth Anyone?” eZinearticles.com , February 22, 2006. Available at http://ezinearticles.com.
  18. For instance, in the United States 97 percent of hospital charges are paid by third parties.  Devon M. Herrick and John C. Goodman, “The Market for Medical Care: Why You Don't Know the Price; Why You Don't Know about Quality; And What Can Be Done about It,” National Center for Policy Analysis, Policy Report No. 296, March 12, 2007.
  19. Manuel Roig-Franzia, “Discount Dentistry, South of the Border,” Washington Post , June 18, 2007.
  20. Devon Herrick, “Health Plans Adding Foreign Providers to Their Networks,” Health Care News , July 1, 2007.  Also see Fraser, “Employers Increasingly Tapping Medical Tourism for Cost Savings.”
  21. Roig-Franzia, “Discount Dentistry, South of the Border.”
  22. Alfredo Corchado and Laurence Iliff, “Good Care, Low Prices Lure Patients to Mexico,” Dallas Morning News , July 28, 2007.
  23. Ibid.
  24. Chris Hawley, “Seniors Head South to Mexican Nursing Homes,” USA Today , August 16, 2007.
  25. Devon Herrick (moderator), Milica Bookman and Rudy Rupak, “Global Health Care: Medical Travel and Medical Outsourcing,” National Association for Business Economics, Health Economics Roundtable Teleconference, July 25, 2007. Available at http://www.nabe.com/podcasts/070725hrt.mp3. Accessed July 27, 2007.
  26. Figures for July 2005.  See “World Factbook: Costa Rican People,” Yahoo.com, 2007.
  27. “Health Care in Panama,” International Living , undated.  Available at http://www.internationalliving.com/panama/healthcare.html.  Accessed July 27, 2007.
  28. Catherine Keogan, “Panama's Health Tourism Boom,” EzineArticles , May 31, 2007.
  29. There is currently a moratorium on building new specialty hospitals because it is thought they drain away lucrative, less acute cases from community hospitals.  Yet there is little debate that this competition improves quality.  For a discussion of specialty hospitals, see Leslie Greenwald et al., “Specialty Versus Community Hospitals: Referrals, Quality, And Community Benefits,” Health Affairs , Vol. 25, No. 1, January/February 2006.
  30. Some of these include: GlobalChoiceHealthCare.com, MediTourInternational.com, Indomedics.com, QuestMedTourism.com, MeritGlobalHealth.com, MyCareWeb.com, MedJourneys.com, HealthBase.com, MeSisOnline.com, GlobalMedicalServices.us, MedSourceIntl.com, MedicalNomad.com, AxiomHealth.org, HealthTraveler.net, HospitalBiblicaMedicalTourism.com, MyNovus.com, Medical-Tourism.FiveSites.com, 5Greatest.com, Surgicalcareinternational.com, Companionglobalhealthcare.com, Thailandvacationtour.com, Virginia.IQmedica.com, UniversalSurgery.com, Medical-Tourism-Guide.com, Bairesalud.com, TreatMeAbroad.com, Medical-travel-asia-guide.com and MediTourIndia.net.
  31. Krysten Crawford, “Medical Tourism Agencies Take Operations Overseas,” Business 2.0 Magazine , August 3, 2006.
  32. Julie Davidow, “Cost-Saving Surgery Lures ‘Medical Tourists' Abroad,” Seattle Post-Intelligencer , July 24, 2006.
  33. Jennifer Alsever, “Basking on the Beach, or Maybe on the Operating Table,” New York Times , October 15, 2006.
  34. Sarah Dawson with Keith Pollard, “Guide to Medical Tourism,” TreatmentAbroad.net, 2007; and http://www.cosmeticplasticsurgerystatistics.com/costs.html.
  35. At an average of about $1,038, an MRI for breast cancer screening costs about 10 times more than a mammogram.  See Sylvia K. Plevritis et al., “Cost-Effectiveness of Screening BRCA1/2 Mutation Carriers with Breast Magnetic Resonance Imaging,” Journal of the American Medical Association , Vol. 295, No. 20, May 24/31, 2006, Table 3.  Also see Devon Herrick, “Medical Tourism Prompts Price Discussions,” Health Care News, October 1, 2006.
  36. Bruce Stokes, “Bedside India,” National Journal, May 5, 2007.
  37. Steven Berger, “Analyzing Your Hospital's Labor Productivity,” Healthcare Financial Management , April 2005.
  38. Bruce Stokes, “Bedside India.”
  39. Ibid.
  40. Herrick and Goodman, “The Market for Medical Care.”
  41. Centers for Medicare and Medicaid Services, “National Health Expenditures by Type of Service and Source of Funds: Calendar Years 2004-1960,” Department of Health and Human Services, 2006.
  42. “Core Health Indicators, 2004,” World Health Organization.  Available at http://www.who.int/whosis/database/core/core_select.cfm.
  43. Herrick and Goodman, “The Market for Medical Care.”
  44. Julie Appleby, “Ask 3 Hospitals How Much a Knee Operation Will Cost … and You're Likely to Get a Headache,” USA Today , May 9, 2006.
  45. See “2006 Consumer Attitudes Survey,” Great-West Healthcare, 2006. Available at http://www.greatwesthealthcare.com/C5/StudiesSurveys/Document%20Library/m5031-gwh-consumer-attud-survy-06.pdf.  Access verified May 21, 2006.
  46. Herrick and Goodman, “The Market for Medical Care.”  For more about competition, bundling and repricing services, see Michael E. Porter and Elizabeth Olmsted Teisberg, Redefining Health Care: Creating Value-Based Competition on Results (Boston, Mass.: Harvard Business School Press, 2006).
  47. Since Medicare patients are an important source of revenue for many physicians and hospital networks, the moratorium has effectively prevented the opening of new specialty hospitals.  See Bonnie Booth, “AMA: Don't Extend Moratorium on Specialty Hospitals,” American Medical News , December 27, 2004.
  48. For a discussion of new techniques in hospital efficiency, see Vanessa Fuhrmans, “A Novel Plan Helps Hospital Wean Itself Off Pricey Tests,” Wall Street Journal , January 12, 2007.
  49. Stokes, “Bedside India.”
  50. Ibid.
  51. Mark Roth, “Surgery Abroad an Option for Those with Minimal Health Coverage,” Pittsburgh Post-Gazette, September 10, 2006.
  52. State laws that ban the so-called corporate practice of medicine are the result of medical societies' attempts to maintain control over the practice of medicine.
  53. For a list of issues patients should consider, see Sidney M. Wolfe, Editor, “Patients without Borders: The Emergence of Medical Tourism, Part 2,” Public Citizen Health Research Group, Health Letter , Vol. 22, No. 9, September 2006.
  54. Bruce Cunningham, President of the American Society of Plastic Surgeons, Statement Before the Special Committee on Aging, United States Senate, June 27, 2006.  Available at http://aging.senate.gov/events/hr159bc.pdf.  Access verified June 22, 2007.
  55. Zhongmin Li et al., “Coronary Artery Bypass Graft Surgery in California: 2003 Hospital Data, California CABG Outcomes Reporting Program, Office of Statewide Health Planning and Development, February 2006.”  Available at http://www.oshpd.cahwnet.gov/HQAD/Outcomes/Studies/cabg/2003Report/2003Report.pdf.  Access verified June 22, 2007.  Some international hospitals, including Apollo Hospital Group, Wockhardt Hospitals and Escorts Health Institute (all in India), claim cardio bypass graft surgery mortality rates of less than 1 percent.  A recent study found high-volume California hospitals have a mortality rate of nearly 3 percent.  For more information, see Milstein and Smith, “Will the Surgical World Become Flat?”
  56. The mortality rate for primary isolated CABG is 0.6 percent.  See Cleveland Clinic Foundation Web Site.  Available at https://www.ccf.org/heartcenter/pub/about/specialties/cvsurgery.asp.  Access Verified June 22, 2007.
  57. Ibid and Zhongmin Li et al., “Coronary Artery Bypass Graft Surgery in California: 2003 Hospital Data, California CABG Outcomes Reporting Program, Office of Statewide Health Planning and Development, February 2006.”  Available at http://www.oshpd.cahwnet.gov/HQAD/Outcomes/Studies/cabg/2003Report/2003Report.pdf. Access verified June 22, 2007.
  58. Harvard Medical International's Web site is http://www.hmi.hms.harvard.edu/about_hmi/overview/index.php.
  59. See http://www.dhmc.org/qualitymeasures/ and http://www.clevelandclinic.org/quality/outcomes/.
  60. “Recognition of Our Clinical Achievements,” National Healthcare Group (Singapore), 2006, Clinical Quality Measures.
  61. Apollo Hospital Group Web site.  Available at http://www.apollohospitals.com/QualityAssurance.asp.  Access verified June 22, 2007.
  62. Herrick, “Medical Tourism Prompts Price Discussions.”
  63. These hospitals used the Global Care Solutions' software.
  64. Richard Hillestad et al., “Can Electronic Medical Record Systems Transform Health Care?” Health Affairs , Vol. 24, No. 5, September/October 2005, pages 1,103-17.
  65. Herrick and Goodman, “The Market for Medical Care.”
  66. Joint Commission International Web site: http://www.jointcommissioninternational.com/
  67. Julie Appleby and Julie Schmit, “Sending Patients Packing,” USA Today , July 27, 2006.  Since this article appeared, the Joint Commission has accredited nearly 50 additional foreign hospitals.
  68. The Indian Healthcare Federation is made up of about 60 hospitals.  See “Indian Hospitals Lure Foreigners with $6,700 Heart Surgery,” Bloomberg News , January 27, 2005.
  69. Communication between NCPA president John C. Goodman and Cleveland Clinic President Delos M. Cosgrove, April 26, 2007.
  70. See the Harvard Medical International Web site at http://www.hmi.hms.harvard.edu/about_hmi/overview/index.php.
  71. “Health Care in Panama,” International Living .
  72. Milstein and Smith, “Will the Surgical World Become Flat?”
  73. Corchado and Iliff, “Good Care, Low Prices Lure Patients to Mexico.”
  74. See Bumrungrad's Web site at http://www.bumrungrad.com/.
  75. See Planethospital's Web site at http://www.planethospital.com/doctors-and-hospitals/.
  76. See PlasticSurgeryJourneys.com.
  77. See  http://www.healthmedicaltourism.org.
  78. See http://www.beautyfromafar.com/.
  79. This combination of surgeries is sometimes called the “mommy makeover.”  See Natasha Singer, “Is the ‘Mom Job' Really Necessary?” New York Times , October 4, 2007.
  80. Ibid.
  81. Several anecdotes are posted on PlasticSurgeryJourneys.com.
  82. See “Consumers Go Abroad in Pursuit of Cost-Effective Healthcare, ” Managed Healthcare Executive, Vol. 16, No. 7, July 2006.
  83. Roth, “$12 for a Half Day of Massage for Back Pain.”
  84. Alsever, “Basking on the Beach, or Maybe on the Operating Table.”
  85. Joseph McMenamin, “Medical Tourism and Legal Liability,” Medical Travel Today, CPR Communications, Vol. 1, No. 1, September 2007.
  86. For instance, see Tracy Correa, “Traveling Can Help Cure Medical Costs,” Fresno Bee , June 19, 2007.
  87. Quotes are available online at http://www.aosassurance.com/PublicHtml/index.htm.
  88. For specific remedies, see Agreement.  Available at http://www.aosassurance.bb/PublicHtml/Documents/PMMI/PMMI%20policy%20wording%20(2).pdf.  Accessed September 18, 2007.
  89. Unmesh Kher, “Outsourcing Your Heart,” Time Magazine , May 21, 2006.
  90. Joyce Howard Price, “Under the Knife Overseas,” Washington Times , December 3, 2006. Also see Kher, “Outsourcing Your Heart.”
  91. Grant Gross, “Analyst: Outsourcing Can Save Costs in Health Care,” InfoWorld , November 16, 2004.
  92. For a discussion on telemedicine, see Anthony Charles Norris, Essentials of Telemedicine and Telecare (New York: John Wiley and Sons, 2002).
  93. For information how telemedicine might impact rural areas, see James Grigsby, Richard Morrissey and Dena S. Puskin (presenters), “Telemedicine in Rural Areas: Research Findings and Issues for States,” Agency for Healthcare Research and Quality, Conference on Strengthening the Rural Health Infrastructure (Asheville, N.C.), November 19-21, 1997.
  94. Robert M. Wachter, “The ‘Dis-location' of U.S. Medicine — The Implications of Medical Outsourcing,” New England Journal of Medicine , Vol. 354, No. 7, February 16, 2006.  For a layman's view of outsourcing radiology, see Associated Press, “Some U.S. Hospitals Outsourcing Work,” MSNBC.com, December 6, 2004.
  95. Associated Press, “Some U.S. Hospitals Outsourcing Work,” MSNBC.com, December 6, 2004.  Available at www.msnbc.msn.com/id/6621014/.  Accessed April 27, 2007.  See Nighthawk Radiology Services Web site: http://www.nighthawkrad.net/.
  96. Robert M. Wachter, “International Teleradiology,” New England Journal of Medicine , Vol. 354, No. 7, February 16, 2006, pages 662-63; Milstein and Smith, “Will the Surgical World Become Flat?”
  97. “NHS Scans to be Sent Abroad” BBC News, July 9, 2004.
  98. Conversation with Rudy Rupak, president of PlanetHospital, Spring 2007.
  99. For instance, see Gina Kolata, “Looking Past Blood Sugar to Survive with Diabetes,” New York Times , August 20, 2007.
  100. For instance, a doctor and nurse practitioner working as a team were better able to manage chronic conditions than a physician working alone.  See David Litaker, “Physician-nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients' perception of care,” Journal of Interprofessional Care , Vol. 17, No. 3, August 2003, pages 223-37.
  101. Jane Anderson, editor, “Use of Telemedicine Tools Grows within DM,” Disease Management News , Vol. 12, No. 8, 2007.
  102. For instance, children assigned to interactive disease management for asthma fared better than those in a control group with traditional disease management.  See Ren-Long Jan et al., “An Internet-Based Interactive Telemonitoring System for Improving Childhood Asthma Outcomes in Taiwan,” Telemedicine and e-Health , Vol. 13, No. 3, June 2007, pages 257-68.
  103. Fraser, “Employers Increasingly Tapping Medical Tourism for Cost Savings.”
  104. Arnold Milstein, Written Testimony to the U.S. Senate, Special Committee on Aging, June 27, 2006.
  105. Herrick, Bookman and Rupak, “Global Health Care: Medical Travel and Medical Outsourcing.” Also see Bookman and Bookman, Medical Tourism in Developing Countries (New York: Palgrave Macmillan, August 7, 2007).
  106. Interview with Elise Anderson, spokeswoman for BlueShield of California, May 4, 2007.  Also see Herrick, “Health Plans Adding Foreign Providers to Their Networks.”
  107. Ibid.  In addition to BlueShield of California, plans are offered through SIMNSA and Health Net of California.
  108. These types of plans tend to be about 40 percent less expensive than comparable plans with U.S.-based networks.  See Corchado and Iliff, “Good Care, Low Prices Lure Patients to Mexico.”
  109. Sarah Skidmore, “Cross-Border Health Insurance Is a Hit with Employers and Workers,” San Diego Union-Tribune , October 16, 2005.
  110. “BlueCross BlueShield and BlueChoice HealthPlan Pioneer Global Healthcare Alternative,” BlueCross BlueShield of South Carolina, Press Release, February 8, 2007.
  111. Joe Cochrane, “Why Patients Are Flocking Overseas for Operations,” Newsweek International , October 30, 2006.
  112. Ibid.
  113. Daniel Yi, “U.S. Employers Look Offshore for Healthcare,” Los Angeles Times , July 30, 2006.
  114. Limited benefit health plans are becoming common.  TennCare, the Tennessee program to boost health insurance among moderate-income families and small employers, uses a limited benefit plan with an annual cap of $25,000.  An actuary from the consulting firm Milliman USA estimates that only 2 percent of enrollees are likely to exceed the $25,000 cap in any given year.
  115. See Chad Terhune, “Covering the Uninsured, But only up to $25,000,” Wall Street Journal , April 18, 2007.
  116. Herrick, Bookman and Rupak, “Global Health Care: Medical Travel and Medical Outsourcing.”
  117. Herrick, Bookman and Rupak, “Global Health Care: Medical Travel and Medical Outsourcing.” Also see Bookman and Bookman, Medical Tourism in Developing Countries.
  118. Aaditya Mattoo and Randeep Rathindran, “How Health Insurance Inhibits Trade in Health Care,” Health Affairs , Vol. 25, No. 2, March/April 2006, pages 358-368.
  119. Graham T. McMahon, “Coming to America — International Medical Graduates in the United States,” New England Journal of Medicine , Vol. 350, No. 24, June 10, 2004, pages 2,435-37.
  120. Greg Siskind, “U.S. Savior: Foreign Doctors,” USA Today , July 31, 2007.
  121. Amy Hagopian, Matthew J. Thompson, Emily Kaltenbach and L. Gary Hart, “Health Departments' Use of International Medical Graduates In Physician Shortage Areas,” Health Affairs , Vol. 22, No. 5, September/October 2003, pages 241-249.
  122. Heather Stringer, “Foreign Investments,” Nurse Week, June 6, 2002. Also see Morgan Lee (Associated Press), “Foreign Nurses Sought to Fill Void,” CBS News, June 29, 2004.
  123. Wolfe, ed., “Patients without Borders: The Emergence of Medical Tourism.”
  124. Herrick, Bookman and Rupak, “Global Health Care: Medical Travel and Medical Outsourcing;” and Bookman and Bookman, Medical Tourism in Developing Countries .
  125. Bookman and Bookman, Medical Tourism in Developing Countries .
  126. The American Society of Plastic Surgeons has come out against medical travel.  The American Medical Association has devised a set of recommendations for medical travel.  See “Medical Travel Outside the U.S.”  June 2007.  Available at http://www.ama-assn.org/ama1/pub/upload/mm/21/a07rep-b.pdf.  Accessed September 18, 2007.
  127. Medicare benefits are not available to seniors living or traveling abroad.  State Medicaid programs do not cover services provided outside the United States.
  128. Milstein and Smith, “Will the Surgical World Become Flat?”
  129. Paul B. Ginsburg and Ernest Moy, “Physician Licensure and the Quality of Care: The Role of New Information Technologies,” Regulation , Cato Institute, Vol. 15, No. 4, Fall 1992.  For a literature review of the history of medical licensure, see John C. Goodman and Gerald Musgrave, Patient Power: Solving America's Health Care Crisis (Washington, D.C.: Cato Institute, 1992).
  130. Economists argue that government regulators are often “captured” by the industries they regulate.  Once captured, the regulators tend to protect the interests of the industry to the detriment of the people they are supposed to protect.  Allowing small groups of physicians, backed by the power of law, to decide who practices medicine and what constitutes the safe practice of medicine may reduce quackery.  But it also is likely to reduce competition and innovation — and protect the incomes of physicians.  See Reuben Kessel, “Price Discrimination in Medicine,” Journal of Law and Economics , Vol. 1, October 1958, pages 20-53.
  131. Kessel, “Price Discrimination in Medicine.” The theory is that price-cutting would lead to a situation where fees would be too low for a physician to render quality services.  For a review of health insurance regulation, see John C. Goodman, The Regulation of Medical Care: Is the Price Too High? (San Francisco, Calif.: Cato Institute, 1980).  Also see Greg Scandlen, “100 Years of Market Distortions,” Consumers for Health Care Choices, May 22, 2007.
  132. For instance, many providers oppose telemedicine.  See Mary Schmeida, Ramona McNeal and Karen Mossberger, “Policy Determinants Affect Telehealth Implementation,” Telemedicine and e-Health , Vol. 13, No. 2, April 2007, pages 100-107.
  133. Stokes, “Bedside India.”
  134. The American Medical Association (AMA) has come out against prescribing medication over the Internet prior to a physical examination. Richard F. Corlin, President, American Medical Association, letter to the editor, “AMA to The Wall Street Journal : Shut Down Illegal Internet Pill Pushers,” Wall Street Journal , November 6, 2001.
  135. For example, a patient with a chronic condition might prefer a convenient location to have blood pressure taken or blood drawn.  A foreign physician might work for a primary care physician and manage a chronic condition for the patient.
  136. Josef Woodman, “Medical Travel Safe for Informed Consumer,” The Tennessean , May 4, 2007.
  137. Interview with Rudy Rupak of PlanetHospital.
  138. Herrick, “Medical Tourism Prompts Price Discussions.”
  139. Joseph Marlowe and Paul Sullivan, “Medical Tourism: The Ultimate Outsourcing,” AON Consulting, Forum, March 2007.
  140. Ibid. Currently, patients pay less for in-network hospitals compared to selecting the best hospital that may not be in the health plan network.
  141. Milstein and Smith, “Will the Surgical World Become Flat?”
  142. Ernst, “Medical Tourism: Why Americans Take Medical Vacations Abroad.”
  143. Corchado and Iliff, “Good Care, Low Prices Lure Patients to Mexico.”
  144. Mark A. Cwiek et al., “Telemedicine Licensure in the United States: The Need for a Cooperative Regional Approach,” Telemedicine and e-Health , Vol. 13, No. 2, April 2007, pages 141-47.
  145. See “Medical Travel Outside the U.S.” Adopted recommendations of Governing Council Report B with a change in title, and filed the remainder of the report, June 2007.  Available at http://www.ama-assn.org/ama1/pub/upload/mm/21/a07rep-b.pdf.  Accessed September 18, 2007.
  146. Milstein and Smith, “Will the Surgical World Become Flat?”
  147. Mattoo and Rathindran, “How Health Insurance Inhibits Trade in Health Care.”

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