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Looking for Solutions in Health Care for 2006 and Beyond

Our health care system needs to change to accommodate new demographics, new technologies and new pharmacologic advancement.

The roots of compassion and caring in health care should not change however, and it is with this in mind that the dialogue of change should be had surrounding health care.

How can we adapt to different needs that emerge as our population ages?

How can we  find sustainability in the midst of so many new advancements?

How can individuals become more empowered in serving their own health care needs?

What role does the individual have in enabling the  health care of others  beyond paying taxes?

Many questions like these need to be answered and if we are willing to look with open minds at the problems within our health care system, and beyond political posturing, then we can find new  solutions to take us further into this century. 

 

 

 

 

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Thursday
Sep082016

B.C. Courts will bring into Focus the Hard Questions about Canada’s Health Care System

 

Canada’s health care system has been called many things including a “jewel” and “the very essence of what Canada is all about”. It has also been called “sclerotic”, “archaic” and for politicians it has become “a sacred cow”. For many Canadians, our health care system has become a mirage. Aside from the illusory notion that our health care is “free”, many cannot explain how it works and how it is financially sustained. Many cannot access the care they need.

However, this mirage is going to be drawn into clear focus in the weeks and months ahead as the B.C. Court is hearing a case put forward by surgeons and patients that accuse the B.C. government of denying them their rights to timely medical care.

Perhaps the B.C. case will allow Canadians to begin the necessary discussions about how our health care must change to address the serious systemic shortfalls within it. We have a strained health care system due to an increasingly aging population, more pharmaceutical options, more medical technology with associated potential interventions, and emerging science that requires more medical research and money.   

For people waiting for care, or denied care, or whose disease is treatable elsewhere but not here, the limitations of our current system have become numbingly clear.  We should walk a mile in patients’ shoes to understand the importance of the B.C. Charter Challenge for those who have been denied timely care. While the outcome of the case is important at an individual level, it will also resonate at a societal level – throughout our country.

Some people choose to frame the case as a “private vs public” health care battle and foresee the destruction of Medicare if B.C.’s provincial health care service loses the case. However, at a foundational level, the case is a challenge about the rights of Canadian patients in a system that denies timely care.  What rights does a patient have? What recourse should a patient have? What suffering can the government health insurance plan fairly impose on an individual patient, if any?  (In a country that has recently witnessed the Supreme Court of Canada rule in favour of an individual’s right to die, one might expect that it would also rule in favour of an individual’s right to live.)

Now is the time to ask the difficult questions about what we want from our health care system that was designed for another era and which, despite transformation, is a laggard in the developed world. Many of us who have been part of the on-going debate about patients’ rights and the short-comings of the system recognize that we can and must preserve what is fair and equitable about Canada’s health care system and move forward to improve what is not.  

There are some important questions that must be fully discussed.

Must we pit patient against the system? What is more important, the patient or the system? Can we not all agree the system must exist for patients? So, the question then becomes “How to provide more care to more patients?” In that context, how is it ethical to preserve a system that cannot meet patient demand despite almost fifty years of trying?

How comprehensive a system can we afford? Do Canadians want modern health care that keeps up with change, or do they want an archaic system designed for fifty years ago? As pharmaceuticals become more and more prominent in treatment options, many Canadians want to include pharmacare in our country. However, the cost of Canada’s government funded system makes it difficult to move forward in publicly funding other areas of care such as eye care, dental care, and newer pharmaceuticals for cancer and other previously untreatable diseases.  How can a better balance of services be achieved that will meet our expectations for an advanced health care system?

There’s the important issue of “Universality”. Do Canadians want universal health care coverage in theory or in reality? The term “universal” does not mean “government funded”. It simply means coverage for everyone. There are many ways to provide coverage for everyone in a truly universal system that creates access instead of imposed rationing. Many other countries have hybrid systems for medically necessary care and manage to achieve universality at lower cost and with better outcomes. Why aren’t we looking at and learning from other better performing systems? And, what of portability of care in Canada? Do Canadians want a system that provides similar services across the country, or do they want the system to be determined simply by the degree of rationing required in each province?

What is to be done about the under-utilized infrastructure and medical workforce? What do Canadians want, more government rationing of care or more ways for more patients to access care? Canada has less than the average number of physicians per capita compared to many developed countries yet we cannot fully employ our medical workforce due to costs associated with utilization of government funded services. Operating rooms and surgeons sit idle, hospital beds may exist but are “unfunded”. Hybrid systems of other developed countries have more providers, more hospital beds, and better access to medically necessary care at lower cost than Canada’s health care system.

Canadians must have this honest and difficult discussion about our health care system if we are to create a truly universal system with quality health care that addresses patient need. I believe the B.C. Charter Challenge will help in this dialogue. Contrary to rhetoric about the case being an attack on Medicare, it is not. Given the history of our country, Medicare will continue, but we must acknowledge its faults. A more robust health care system is needed, one that is truly universal, comprehensive, and accessible and not so negatively impacted by government short comings both in funding and in vision.

The B.C. case will bring our health care system into much clearer focus. It will drill to the core of the debate. If we are to give patients the dignity and respect they deserve, then we must acknowledge that they are part of the solution and give them the necessary freedoms that are currently lacking.

Reader Comments (556)

From the NP editorial " the defence of the of the government's catastrophic handling of the province's electrical sector ( and the health care sector for that matter) is typical of the Liberal government's habit of giving themselves full credit for their noble intentions, whilst refusing to accept any blame for unintended , albeit foreseeable, consequences..."
September 13, 2016 | Unregistered CommenterAndris
Culpability is apportioned with disproportionate liability to the deepest pocket around the table. The aggravation lies in the cross claim. The attending has at all times the duty of care and must seek transfer to a capable facility if the present is lacking.
September 13, 2016 | Unregistered Commentereklimek
“At issue is the extent to which the problems are indicative of the whole. Overall the quality of care is among the best in the world. The patients who are waiting too long are the exception not the rule.”

http://www.ottawacitizen.com/news/national/mulgrew+groundbreaking+suit+threatens+universal+medicare/12187934/story.html
September 13, 2016 | Unregistered Commentereklimek
So the Lieberals are going to be another billion dollars short which must be recovered by the next election. Except Hoskins to ramp up the cuts particularly to those high billers.

"Saving the sales tax will be nice, of course. But the government still has to pay for all those hospitals and schools, so it’s going to have to get that money from somewhere else. As any economist will tell you, across-the-board cuts (subsidies) to energy costs are always a sop to the rich, since the well-off consume a greater share of power to run their 4,000 square-foot McMansions. This plan is expected to drain $1-billion from provincial coffers. It’s a shell game they’re playing. It’s still your pocket that’s being picked."

http://www.theglobeandmail.com/opinion/wynnes-way-rob-the-poor-help-the-rich/article31835620/
September 13, 2016 | Unregistered CommenterCanary in a Coal Mine
Regarding those high billers - they picked the wrong nation in which to live like Americans, square pegs trying to fit in round holes. As MFO would say, they are too close to the margins, they likely need to be eliminated to set an example. That's a reminder to me to watch that a007 to a001 ratio, ensure things stay near the median. To those who choose not to blend in, go south, or go west, you don't gotta go home but you can't stay here!
September 13, 2016 | Unregistered Commenterdocinthepark
<< you don't gotta go home but you can't stay here!>> - DITP

Closing Time by Semisonic (1998) from the album Feeling Strangely Fine.
https://www.youtube.com/watch?v=3xzDm5v7lXI

Appropos tune! Well done DITP.
September 13, 2016 | Unregistered CommenterExecutive Lead Blogger
Electrical power: Issue is consuming central.Serious problem with no federal plan developed.

Health,frozen,with hospitals being advised to squeeze more.
September 14, 2016 | Unregistered CommenterMovingforwardOntario
The ER Doctor should roll the hot potato patient to the hospital CEO's office....then run.
September 14, 2016 | Unregistered CommenterAndris
It is going to be a very tough next two years, with the health and electricty issues. Get as far as you can into the middle of the pack, because the margins are really going to take hits. This is going to be very unpleasant..
September 14, 2016 | Unregistered CommenterMovingforwardOntario
Has anyone ever characterized being on a waiting list as a public health problem?, in other words, how much life is lost due to being deprived of definitive health care?
September 14, 2016 | Unregistered CommenterEklimek
DrK

Most life insurance companies can calculate cost of waiting lists/no treatment. It is how they help adjust their rates.
September 14, 2016 | Unregistered CommenterMovingforwardOntario
Some advice. The next two ears is a straight ideological struggle. Social justice versus fair payment for work. Social justice will win,doctors will be receiving less money per service, for the "good of us all".
September 14, 2016 | Unregistered CommenterMovingforwardOntario
Mfo, with that said, I predict a money dump in a future cycle maybe 10 years out to offset the manpower shortage they will create, especially in primary care. The push for evidence may also reveal that team based health care wasn't all it was cracked up to be, making solo and small group GPs worth their weight in gold. A future more fiscally conservative government may not be willing to fund alphabet soup mega teams especially if good data is lacking.
September 14, 2016 | Unregistered Commenterdocinthepark
http://m.torontosun.com/2016/09/14/cupe-sues-premier-kathleen-wynnes-ontario-government-over-hydro-one-sale

Now we're getting somewhere! Time to unmask and reveal the depth of corruption in this government.

This has me thinking, maybe the trade-off of losing corporation and small business privileges would be offset by the benefits of unionization. I don't particularly care to run an office or hire /fire staff anyway, let us all be government lifers, I think I might learn to love big brother!
September 14, 2016 | Unregistered Commenterdocinthepark
DITP....there is, of course, no evidence that the much favour alphabet soup capitated team clinics are superior, more effective, in particular cost effective, more efficient, than the small group/ solo practices that the government wants to be eradicated.

Resurrecting old skills is very difficult ....the Soviets , with collectivization, team based collective and state farms, destroyed the small landholders, the small farmers and destroyed their voluntary cooperatives.

Agriculture collapsed, the USSR / Ukraine which had been the bread basket of the world , became , instead, a net importer of grain and food, with mass starvation , the Homodor...murder by starvation of 7-10,000,000 not to mention the deportation to Siberia of so many more.

The skills and knowledge of the murdered / deported peasant farmers was lost...the remaining teams of Soviet agricultural bureaucrats were completely out of their depth, blundering about incompetently with disastrous results and declining productivity.

Two decades after the happy collapse of the Soviet block, the agricultural decline has not recovered....perhaps it is bottoming.

Modern day Russia is hoping to attract back to Russia the ancestors of the Old Believers once exiled with their skills ( learned over a 1000 years) in sustainable forms of agriculture, with their ability to survive in harsh conditions and ability to live in harmony with nature....to recolonize the very lands , now lying abandoned and fallow, that they were removed from.

There were 15-20, 000,000 prior to 1917....perhaps there are some 5,000,000 surviving now world wide , living in the USA, Canada , Australia, New Zealand , Brazil, Uruguay and Argentina.

Solo / Small group FPs resemble the Old Believers in many way...however their skills will die with them.
September 14, 2016 | Unregistered CommenterAndris
Goal of the next two years: target the high billers. It works in the polls. This is the politics of envy and the current government will be using the polls to maintain its electability. Anyone billing more than $500,000.00 per year will be targeted. It works with the public.

Bill 210 will get passed so that local boards determine terms and conditions of where and how one can do medicine in their area. Only the conformers will be accepted.
September 15, 2016 | Unregistered CommenterMovingforwardOntario
High billers:

Central will spend the next 2 years,focusing on "high billers".It has no solutions to health care, so can only focus of those whom they can blame for health cares woes. Healthcare is not working because of "high billers". By applying "social justice" policies, and bringing the "high billers" under control, all will be fine.

Those top 2000 are about to be demonized.
September 15, 2016 | Unregistered CommenterMovingforwardOntario
"Central will spend the next 2 years,focusing on "high billers".

No surprise here. Every government rediscovers and finds it a short term response but not a solution.

From
JULY 1, 1992 CAN MED ASSOC J 1992; 147 (1) 33

Toward integrated medical resource policies
for Canada: 6. Remuneration of physicians
and global expenditure policy
Greg L. Stoddart, PhD; Morris L. Barer, PhD


"We do not find individual income thresholds a
particularly appealing policy option, except as a "last
best" (or perhaps "first but temporary") instrument
to stimulate a more constructive and collaborative
development of other policies to manage physician
resources. If quality of care is an issue, then an
improved system of continuing competence assessment
seems to us a preferable policy. If proliferation
of services is a concern, then decreased reliance on
the fee-for-service method seems preferable. We
share the widely held concerns about the current
levels and distribution of physicians' incomes; however,
we also share concerns that thresholds, unless
carefully designed, may "penalize the good guys."
An integrated set of revisions to quality assurance,
remuneration method and physician supply policies
should be the objective here."
September 15, 2016 | Unregistered Commentereklimek
DrK

Central just needs a short term strategy and tactic, to divert attention from solving an insolvable ideological dilemna.
September 15, 2016 | Unregistered CommenterMovingforwardOntario
<<Central just needs a short term strategy and tactic, to divert attention from solving an insolvable ideological dilemma.>> - mfO

Diversion is - in plain fact - Central's ONLY tactic.
September 15, 2016 | Unregistered CommenterExecutive Lead Blogger
BC supreme court update

http://www.thestarphoenix.com/news/national/mulgrew+chicken+little+arrives+complex+medicare+trial/12194155/story.html


"The real issue in this case is about data — are medical waiting lists so bad that people are dying or suffering physical and psychological damage to an extent that court intervention is required to stop harmful consequences of a fine-sounding government policy?"
September 15, 2016 | Unregistered Commentereklimek
The issue is how much public resource are we prepared to pay, to cover more and more expensive care for more marginal conditions?
September 15, 2016 | Unregistered CommenterMovingforwardOntario
perspective changes and the matter morphs.

The issue is - can government prohibit access to medically necessary treatment while failing to provide it? If so, under what circumstances?
September 15, 2016 | Unregistered Commentereklimek
The core issues the governments need to balance, and individuals need to monitor. At what point, do you become a state widget? Canada, with its sole provider system, must acknowledge unprovided care is its moral responsiblity.
September 15, 2016 | Unregistered CommenterMovingforwardOntario
"Describing them as audacious scofflaws, a lawyer for a group of patients intervening in the constitutional challenge of the MPA sounded as if she were on a crusade."

- From the star Phoenix link above, wow. My main take home point is that I need to use the term "audacious scofflaw" more often in my day to day conversations!
September 15, 2016 | Unregistered Commenterdocinthepark
If another doc sends in a patient and they feel they need a scan we generally do the test unless it was clearly not indicated. Sometimes it's not until the next day or few days. Medico-legally it would be pretty dumb to do otherwise.
,
Er medicine is tough and we all make the rare bad decision (in retrospect) at 0300. I like sleeping at night so generally error on the side of caution. We don't often get a second crack at the patient and are relying on follow up in the community or not at all so we probably over investigate. That will not change.

A written referral letter faxed or given to the patient is much appreciated. Often the doc that takes the call (if they do call) is not the same one who sees the patient.
September 15, 2016 | Unregistered CommenterERdoc
While on the topic of depriving patients of intervention we have ...

"It’s become abundantly clear that the appropriate processes in place are not working for thousands of Ontario patients like Mayor Macmillan,” she said. “The Minister of Health cannot continue to wash his hands of Ontario patients who are falling through the cracks.”

http://www.torontosun.com/2016/09/15/cancer-stricken-mayor-hec-says-onatrio-health-system-rigged
September 15, 2016 | Unregistered Commentereklimek
So the fiscal 201516 overages are in the OMAs hands,and 1st quarter for fiscal 2016-17. When will the claw-backs expand?
September 15, 2016 | Unregistered CommenterMovingforwardOntario
A tough two years coming up.Stay away from the margins,in all areas.
September 15, 2016 | Unregistered CommenterMovingforwardOntario
Has anyone really given any thought to how the electricity cost issue literally came out of nowhere to absolutely dominate the political agenda? Going as far as to to prompt the proroguing of the Legislature and forcing the Government's hand on an 8% tax rebate.

Electricity has knocked health care and the physician services agreement to a spot after the morning Dilbert comic strip. And no one reads Dilbert anymore!

What lessons are there for the OMA?

P.S. The government is going to lose a billion dollars in tax revenue by eliminating the provincial portion of the HST.

Where do you think the offset is going to come from? Anyone, anyone?

Buehler?
September 16, 2016 | Unregistered CommenterExecutive Lead Blogger
ELB,
Hydro has been on my radar and that of many others for quite some time. Clearly the SRR by-election loss was a wake-up call for KW.
ELB, are you suggesting there is another catalyst?
September 16, 2016 | Unregistered CommenterMerrilee Fullerton
Hospitalists and the Decline of Comprehensive Care
N Engl J Med 2016; 375:1011-1013September 15, 2016DOI: 10.1056/NEJMp1608289

"The hospitalist model has provided such putative benefits as reductions in length of stay, cost of hospitalization, and readmission rates — but these metrics are all defined by the boundaries of the hospital. What we don’t yet know sufficiently well is the impact of the rise of hospital medicine on overall health status, total costs, and the well-being of patients and physicians."
...

"As patient care becomes increasingly fragmented, many physicians find it more and more difficult to provide truly integrated care. Physicians whose practices rest on a clear separation between inpatient and outpatient care or manifest a shift-work mentality are more likely to respond to requests from patients and colleagues with, “Sorry, but that’s not in my job description.”
September 16, 2016 | Unregistered Commentereklimek
R

Power generation is a huge national and provincial issue, and its impact on the economy is now being realized. The transition to renewable energy sources, and off carbon generation, is going to be expensive and painful, and that reality is hitting. It is going to require a lot of public money, and lots of people on limited incomes, particularly in rural areas are being advisedly affected. The HST cut isn't going to solve this.

As for the doctors, that is done. Pot of money defined, deal with it, or leave.
September 16, 2016 | Unregistered CommenterMovingforwardOntario
Electrical power costs and management hits everyone,everyday.Health hits under 10% of the population a year. The public will accept health rationing easier than blackouts..
September 16, 2016 | Unregistered CommenterMovingforwardOntario
Health poverty:

We accept that waiting lists exist,and services are not available,representing our "health poverty".

Energy poverty: we will not solve this with "power outages" or refusal to power certain devices.

Watch carefully the job announcements. The backroom subsidies in tax reduction,and energy at reduced cots are impressive.
September 17, 2016 | Unregistered CommenterMovingforwardOntario
"Power generation is a huge national and provincial issue, and its impact on the economy is now being realized"

You state "now" being realized. I find the premise that the impact of power generation done well or badly could not have been seen as having an impact on the economy.

I'm restraining my reaction to this kind of statement.

Leadership cannot be about doing grandiose, egocentric manoeuvers following the "big hairy audacious goals" mantra of various self-appointed gurus who are not in position to either understand the complexity of the real world or who spend their time publishing what their fantasy world look like. Leadership must be both pragmatic and visionary. Wishful thinking doesn't cut it.
September 17, 2016 | Unregistered CommenterMerrilee Fullerton (realist)
"Watch carefully the job announcements. The backroom subsidies in tax reduction,and energy at reduced cots are impressive."-mfO

Ultimately, the tax payer and all the "fee" payers get hit by this. It creates uncertainty, resentment and a tightening of the purse strings.

Oh my.

On another note, I attended an event in Ottawa yesterday where Kathleen Wynne and entourage showed up. Some people left. Another called her out on an issue. People were avoiding getting in the photo op.

And....despite this, several retired teachers and several others still voiced their approval and support of the Wynne government. They are comfortable. No problem with their hydro costs they say and as far as they are concerned, Wynne is doing a wonderful job in health care....this despite one Wynne supporter lamenting that he cannot find affordable care for his relative with dementia......just keep those rose coloured glasses on for a little longer and keep stumbling along.
September 17, 2016 | Unregistered CommenterMerrilee Fullerton (realist)
R:

The impact of power realignment was recognized years ago,but no long-term planning was allowed to be developed,because it would honest about future changes to lifestyles.

Best example to watch is the transit mess in the GTA. Huge political decsions that will affect the population in massive ways, which can not be discussed,because winners and losers are being picked.

Same as the OMA mess, huge shift in the winners and loser groups will occur.

The struggle between transnational progressives and the nativists is painful to watch!
September 17, 2016 | Unregistered CommenterMovingforwardOntario
" No long term planning allowed"?

So everything is done according to short term expediency and damn the long term consequences a la Keynes " after all, in the long term we are all dead" attitude.

Ontario is doomed.

Ontario health care is doomed if short term expediency is really ruling the roost....has the supposed long term health care planning , involving so many people , so much time and so many $'s , been only a cover story all the time?....seemingly the only long term planning underway revolves around reelection in 2018....after that , who cares, " apres nous le deluge".
September 17, 2016 | Unregistered CommenterAndris
"Nativists".....those favouring Ontarians? Those favouring the Liberals? Those favouring the groups that support the government such as the teachers and the sheltered medical ivory towerists?

" Transnational progressivists"....the post nationalist global citizenship crowd? Those advocating green energy/ global warming crowd? Those advocating the needs of the LGBT crowd? Those advocating the importation of unvetted Islamic refugees from the Middle East asylum ?

So there are two wings in the Ontario Liberal government split along those lines?
September 17, 2016 | Unregistered CommenterAndris
In Ontario,the nativists tend to be associated with the Conservative Party,the "transnational progressive" with the Liberals.

Generalization,but a reasonable explanation of the widening polarization. Those who want ,first,to save the world,on the back of the population it gathers tax from,versus those whom want to govern the local population,as its first goal, and support global efforts with what is left over,once the local needs are reasonably addressed.
September 17, 2016 | Unregistered CommenterMovingforwardOntario
Ok....I hoped that there was a split in the Liberal ranks...so 100% transnational progressivism it is....the enlightened few ruling the stupid unwashed plebeians with a superior insight into all matters....in health care we have the authoritarian enlightened few within the OMA and in the subsidized ivory towers temporarily thwarted by rogue terrorists who emerged out of the slurry of the unenlightened membership.

" A liberal is a man too broad minded to take his own side in a quarrel" ( Robert Frost).
September 17, 2016 | Unregistered CommenterAndris
So one just establishes your personal political position alone the extremes from left to right,and get on with life.The more transnational progressive,the more of persona Independence you are prepared to share,the more nativist, the more you wish to be left alone.

Once you do that,you then must review the proposed OMA contract,and how it will influence your future.That isthe sole offer.It will not change.
September 18, 2016 | Unregistered CommenterMovingforwardOntario
The profession should " swallow their blood and teeth" over the next two years....in the mean time the government will do its worst....but there will be truly negative unanticipated consequences to their actions which will bite them where it hurts.

It is important that the government and its collaborative quislings own the inevitable negative outcomes.....the OMA and allied professional organizations will do their best to give their master cover and blame their own memberships for whatever negative events occur...but the feet of the government will have to be kept to the fire.
September 18, 2016 | Unregistered CommenterAndris
As long as physicians own the means of production the government cannot win the war. If they go after the top 2000 billing docs expect very strong pushback from the entire profession. Tell Hoskins to bring it on and he'll find out very quickly the mush is gone. This will become very personal for many docs.

http://shawnwhatley.com/distract-doctors/
September 18, 2016 | Unregistered Commentercanary in a coal mine
The physicians will not win,in that the ED MDs and surgeons will not stop providing timely care.

First pass,Bill 210.Then deliver the social justice package of physicians as state controlled widgets. Most will comply for the income security. 60% of the practices need the each OHIP deposit to get delivered.
September 18, 2016 | Unregistered CommenterMovingforwardOntario
We don't need ED docs or surgeons to bring the system to a halt. Look at how effective the ob/gyn's threat of job action was a decade ago. There are effective means again to resist the government especially the implementation of bill 210.
September 18, 2016 | Unregistered CommenterCanary in a Coal Mine
Central just needs to do nothing but small continued cuts.
September 19, 2016 | Unregistered CommenterMovingforwardOntario
Interesting that the OMA was purposely editing section communications into a format that members could not read or not sending out communications at all prior to the ballot. Now they want sections to sign multi-page legal documents in order to be granted the privilege of using OMA servers to communicate in a timely fashion with its members.

From one section email sent today to OMA President Dr. Walley:

"In addition, the new, special communication tool that you have noted does not "guarantee that emails will go out, unedited and unreviewed, within 24 hours.” In fact, the email preamble to the new communication tool very clearly stated that communications will be reviewed, and its utilization would require our Section to sign a multipage contract before utilizing the service. We are not going a sign a multipage legal contract just for the ‘privilege’ of communicating with our members. Our ability to communicate with our membership is a right. Setting all that aside, you have told us point blank that this alternate communications network is vastly incomplete as many members have unsubscribed. In effect then the only way to communicate with our full membership is to go through the regular OMA channels that for ten years has held-up, blocked, edited, and censored our communications."
September 19, 2016 | Unregistered CommenterCanary in a Coal Mine

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