In America, where employers are expected to provide health care, older workers are also more expensive to insure.

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Massachusetts state coffers have not been bled to insure self employed persons, such as Gloucester and New Bedford fishermen, and low income workers unable to afford health insurance.

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Earlier efforts to come to an accommodation with religious groups had run into problems because many large employers, including big Catholic institutions, self-insure, meaning they act as insurance companies by assuming the full responsibility for the health costs of their workers and use traditional insurance companies only for administrative services.

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