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Friday, January 2, 2015

Vik Khanna on "the ObamaCare Ignorati"

Vik Khanna recently asked me to read and review his new book. OK. (I've heretofore made references to it on this blog, e.g., here and here.)

I chose the phrase "ObamaCare Ignorati" for the title above after seeing (and filching from) a comment by Vik's frequent publishing partner Al Lewis made over on THCB:
'the “Wellness ignorati” are people whose business depends on making sure facts are ignored'
After a close study of "Your Personal Affordable Care Act" while on Holiday recently, I think it's safe to say that Vik thinks "ObamaCare" is being pushed by "policy ignorati," at the expense of the very public it was ostensibly designed to serve. (For the record, I was never an unalloyed PPACA fan; I've irascibly called it "AHIPcare." See, for example, my 2009 post "Public Optional.")

Useful to start with the Amazon summary.
It should not take an act of Congress to get you to take charge of your health. Unfortunately, if we had all gotten that message, we would not face the massive bamboozling of Americans that is Obamacare. Instead, we have relentless government and its private sector enforcer, the healthcare industry, in hot pursuit of Americans who need more medical care like they need more taxes.

We are the nation of shoulda, coulda, woulda. We should be the fittest society in the world, with a small, efficient, safe, and highly effective medical care system that takes care of only the problems we absolutely cannot resolve for ourselves. We could be a nation of runners, lifters, surfers, cyclists, rowers, martial artists, speed walkers, swimmers, dancers, Zumba-ers, dancercisers, CrossFit-ers, yoga-ers, and so on; we would be people who exercised often (and hard), ate simply, slept abundantly, spent time in silence, and didn’t abuse legal or illegal drugs, alcohol, and tobacco. In short, we would be everything that we are not.

The healthcare industry will not bring you to health, because health is not a medical care product. Yet, this is President Obama's vision, that you can produce more health in the most over-diagnosed, over-tested, over-doctored, over-medicated population on the planet by shoving more people into an entitled, greed-soaked healthcare industry on steroids. It is the biggest strategic miscalculation and misunderstanding in the history of the concept of health.

Time is running short. The way to ruin Obamacare’s sickness-based vision is not to repeal it, but to render it irrelevant. Your Personal Affordable Care Act is the most compelling takedown of Obamacare that you will ever read. But, it doesn't stop there. It also provides an indispensable roadmap to your personal health success. It is also long past time to return the vigorous personal pursuit of good health back to its rightful place as a measure of what it means to be a competent adult. Your Personal Affordable Care Act is your tool for that pursuit, a visible, sustainable, actionable push back against an overzealous government and a rapacious industry.
First, I have never met Vik Khanna (nor his colleague Al Lewis). We are simply online acquaintances by virtue of frequenting the same healthcare blogs. I'm not being paid by anyone to spend time on this, nor am I pimping for pals.

My review:
I am about to do a full review of Vik’s new take-no-prisoners book on my blog. I re-read much of it yesterday during my flight home from back east at my mother in law’s farm for the holidays. Even though there are a few areas regarding which I take (relatively mild) exception, I give it 5 stars and recommend it without reservation. Given its low Kindle price, it is a tremendous value. In sum:
  • Eat sensibly (w/respect to quantity and variety);
  • Don’t smoke, and minimize alcohol consumption;
  • Exercise appropriately and consistently;
  • Get enough sleep;
  • Minimize adverse stressors (including dysfunctional acquaintances);
  • Question Authority relentlessly (in particular the Received Wisdoms of Health Wonkistan);
  • Work on truly knowing yourself and work on pursuits that give you joy and meaning in life. Lose your Jones for banal trivia (e.g., soul-sucking social media and other sedentary entertainments);
  • Insure rationally against catastrophic medical misfortune, and avoid using “health insurance” as routine 3rd party intermediated pre-payment (it’s not really “insurance” anyway).
That’s pretty much it. Not rocket science, not a panacea, but, practices that, if widely adopted, would have dramatic positive population health effects is relatively short order, at nil individual cost.
I finally finished reading the book closely twice. It is now awash in a sea of Kindle Reader yellow highlighter and filled with bookmarks.

It has steadily grown on me, and, I can say, that, were we to meet, I could quickly come to call him a "friend" notwithstanding some political issues regarding which we disagree (he'd warned me in advance that I would probably not agree with every aspect of the book. I don't, but, upon close and candid reflection, the differences are minor). You have to respect a man who has done his empirical homework, and who hews to a consistent, detailed logical argument. I have long felt that I can dispositively refute most putative "libertarians" in just a few minutes of Socratic, so shallow and inconsistent are their dilettante sociopolitical views. Simply being able to pronounce and (misleadingly) cite the likes of Adam Smith, Hayak, Coase, Friedman, Szasz, Ayn Rand, and Austria et al does not a cogent Philosopher make.

Vik is refreshingly different.
Regardless of your political persuasion (full disclosure: I am a non-partisan conservative (1) who leans slightly libertarian, but I find anarchy distasteful, and, at different points in my political life, I have belonged to both major parties. I believe the only thing they share is bottomless incompetence). There are two important apolitical themes underlying this message. First, unless you have a clear genetic defect (such as cystic fibrosis or sickle cell) or already have a serious illness (such as diabetes or heart failure), most of the avoidable health adversity you will face in life can be mitigated by steps you can take to protect yourself, and almost none of them require a doctor or a health bureaucracy for success. You can also improve your health status even if you have an inherited disorder or a serious illness, but the changes will take more time and work, and require vigilant medical supervision.

Vik Khanna. Your Personal Affordable Care Act: How To Avoid Obamacare (Kindle Locations 684-691). 
If you are a conservative, libertarian, Republican, or disaffected Democrat who has been fulminating about Obamacare, I share your frustration. But, if you are also someone who talks a good game about personal responsibility, but doesn’t actually live it, then you are even bigger part of the problem than people who at least are not hypocrites. When you get off your butt, stop drinking to excess and smoking, quit your see-food diet, and start exercising, then you can start talking about what needs to be fixed, how, and why. Otherwise, you’re just a windbag. People who take personal responsibility seriously lead by example. As for liberals who are inclined to reflexively reject my personal responsibility first argument, no less a liberal icon than John F. Kennedy said, to put it mildly, you’re wrong (and weak). (ibid, Kindle Locations 3219-3225).
I’ll answer the anti-vaccine screeching now by saying that no medical service is perfect. All have side effects, and sometimes they don’t work at all. That’s true of both curative services and preventive services. I am all for people deciding yay or nay on their own healthcare needs (I really don’t care if you want to refuse medical care for yourself and hasten your own death), but the libertarian argument gets murky when your decision (you don’t want to vaccinate yourself or your kids against potentially lethal infectious diseases, such as polio) affects others; there is a difference between ordered liberty and anarchy. So, here’s my solution that preserves your freedom to choose. Let’s say that the polio vaccine is 90% effective, and I vaccinate my kid. But, you don’t vaccinate yours and you come home carrying the polio virus after an international business trip. Your kid becomes patient 0 at his school, and my kid develops the disease even though he is vaccinated (remember, I consented to have a vaccination that I knew was 90% effective so I was taking reasonable steps to protect my child and those around him). I should have the right to sue you for medical and non-medical damages, and so should the school district. There, now you get to have your precious choice, but you also bear the cost. (ibid, Kindle Locations 3238-3247).
Further, here’s the central difference between me and most people who label themselves libertarians – I not only believe in free choices in the marketplace, I also believe in personal responsibility and that includes an obligation to behave responsibly toward those around me because without embracing both sentiments, all you have is chaos. It is essential to recognize that on many issues, people have aligned interests and shared risks. This is completely in line with The Theory of Moral Sentiments, by Adam Smith, who actually wrote about our moral responsibilities to each other before he wrote The Wealth of Nations; somehow conservatives and libertarians always cite the latter but act like the former was never written. (ibid, Kindle Locations 3253-3259).
Yeah, the "My Country, 'Tis of ME!" crowd largely have zero clue that the late Adam Smith was a moral philosopher, not an "economist."

Ahhh.hh.h... I feel a song coming on....

I'm not gonna win a Grammy with that one, lol (I have another one in the Logic Pro X oven at the moment). "Free Rider" lyrics just fell out of my head in about 30 seconds the morning after SCOTUS narrowly "upheld" the PPACA a couple of years ago. But, "ObamaCare" will be back in the dock before the Supremes in March, over the lame "exchanges established by the state" clause.

Brought to you by legions of amicus brief ignorati.

Sorry. Back to Vik.
"When you get off your butt, stop drinking to excess and smoking, quit your see-food diet, and start exercising, then you can start talking about what needs to be fixed, how, and why. Otherwise, you’re just a windbag."
He cites the late President Kennedy:
“Thus, in a very real and immediate sense, our growing softness, our increasing lack of physical fitness, is a menace to our security...if our bodies grow soft and inactive, if we fail to encourage physical development and prowess, we will undermine our capacity for thought, for work and for the use of those skills vital to an expanding and complex America. Thus, the physical fitness of our citizens is a vital prerequisite to America's realization of its full potential as a nation, and to the opportunity of each individual citizen to make full and fruitful use of his capacities.” (op cit, Kindle Locations 104-108).
By comparison, Barack Obama’s call to arms over healthcare, which is to empower bureaucracies and embolden private industry to function as the government’s enforcers, is feeble. President Kennedy spoke of health as a responsibility; President Obama speaks of access to healthcare as a “right,” but the problem is that rights without responsibilities are just entitlements. With the Obamacare “right” to healthcare there should have been an unequivocal challenge to Americans to use it as little as possible to help make the industry more efficient, restore fiscal sanity, and preserve resources for the sickest amongst us who really need help. 

President Kennedy’s words, on the other hand, were eerily prescient of our present state of affairs 

You can start living up to President Kennedy’s challenge and rejecting President Obama’s premise at your very next meal. 

Here is the world’s simplest healthy eating advice: Eat less. Eat less crap. 

If we all did only these two things and nothing else, we would make unbelievable progress towards health. In fact, we would do so much that we would begin turning around a healthcare industry that is, in the words of Molly Hatchet, flirting with disaster. Our national disconnect from personal responsibility for healthy eating didn’t happen because we all have an eating disorder. We have, simply, disordered eating because we choose to overindulge and our food industry, the most efficient and productive that the world has ever known, makes it easy for us to do so. Only in America would making food cheaper and more accessible lead us to complain we have actually done something wrong. (ibid, Kindle Locations 109-123).
There is no shortage of targets for Vik Khanna. "Wearables"?
The tech geeks and the quants say they have the answers to saving us. No, not really. 

Not a day goes by that we don’t read about a new fitness device or app that has all the answers we are looking for. The latest and greatest is the forthcoming Athos, which will not only digitally assess fitness measures, most of which you really don’t need to know to build or maintain actual fitness, but will require you to buy a wardrobe of their very expensive sensor clothing for the privilege. 

My favorite fitness app story is that of an acquaintance who told me how the FitBit had improved his life, prompting him to walk more at work and even have his employer provide him with a standing desk. This would all be a very positive step for the many Americans who move too little and sit too much, but this guy is one of the fittest people I know, a physician and an avid cyclist. His habits have already lowered his manageable health risks as low as they can go; using a FitBit isn’t going to change them further. For him, as for many people, tidbits like the FitBit are toys that entertain. I don’t know anyone who needed a FitBit less. On the flipside, there is not much evidence that apps, gadgets, and websites are really having much of an impact on the health of anyone who really needs to find a way to change. Why is that? Because if you are not internally motivated to succeed, a digital toy will not take you there. 

The toys, apps, and websites that we want to do the work for us are the electronic equivalent of unused treadmills and weight machines currently functioning as expensive clothes hangers in basements across the country. Health success doesn’t start with trivia such as “Which running app do you use?” It starts with fundamentals, such as “Do you run [substitute the exercise of your choice] at all?” And, if you don’t, why don’t you? Because somewhere along your road in life, people stopped telling you it was important to do so and that is was okay not to, that it was your choice. Well, see, what happens when you make a lot of bad choices it creates an opportunity for government and institutions that want your money and obedience to come in and start to control your choices. When you start acting like a sheep, someone is going to eventually shear you. 

Maybe someday all the hype about wearables will translate into something beyond making money for the people who make the devices and their related apps. But, until then, the wearables you need to invest time and money in are your attitude, your strategy, and how you wear them for the world to see. Funny thing about self-image and self-respect… the people I know who carry themselves with the most confidence and poise don’t use any of this stuff. They stick to the basics, the indispensables. Everything else is just gravy. (ibid, Kindle Locations 311-335).
Vik's detailed chapters on diet and exercise are compelling. I'm not going to cite things here (this post will end up being too long), just read them for yourself and draw your own conclusions.

The final chapter:
Chapter 6: The 6 big lies about U.S. healthcare 

Our healthcare industry is, without doubt, the most complex and contentious on earth. It is driven, unfortunately, not primarily by understanding the population’s needs and interests, but by the flow of money and power, which express themselves through law and regulations that are written primarily to benefit the healthcare provider and health plan industries. Six tall tales we’ll discuss shortly are worth dealing with head-on because they’re the reason we got Obamacare and why you need Your Personal Affordable Care Act.

According to the Organisation for Economic Cooperation and Development (OECD), no one outspends us when it comes to medical care, but many outlive us (

Even more damning is the fact that every country on the list of nations that both spend less and live longer is also less overweight or obese than we are. We are the fattest culture in the history of Western civilization. 

While many factors influence life span, this is a pretty severe indictment of a healthcare industry that clearly does not deliver value. I think most of us have to come to realistically expect that anytime we buy the most expensive product in a category, we anticipate getting something that is special and valuable. Not so in American healthcare, where we pay for a new Porsche every year and keep getting an AMC Pacer. And, instead of demanding better, we just get in, mumble our thanks, and drive the same piece of junk down the road hoping that, for us at that moment, it doesn’t disintegrate. Why are we so grateful for so little value? 
The healthcare industry’s duplicitous design is not incidental. The more medical care providers ingrain the belief you get healthier only through them, the more money they make and the more power they accrue; this is called intervention bias and it is particularly harmful to people who aren’t ill and don’t need complex clinical services. It’s also harmful when a provider’s financial incentives conflict with the patient’s needs, such as when the cardiology center wants to place a stent in someone’s coronary artery, but doesn’t disclose that stenting would be no more effective than medical management and lifestyle change for many patients, nearly all of whom are operating with an incomplete data set. (ibid, Kindle Locations 2380-2409).
Vik's Chapter 6 closing "six lies":
Lie 1: We needed health reform to solve the problem of people being uninsured for healthcare

Lie 2: We needed a national solution

Lie 3: Insuring the young and healthy will lower costs overall

Lie 4: The ACA helps average people more than it helps the healthcare industry

Lie 5: People need more preventive medical care, which will also help contain costs

Lie 6: Don’t worry, be happy; it’ll all work out
First and foremost, you should worry. There is zero evidence that staying fully and relentlessly engaged with the medical care industry will reduce costs or improve health. Indeed, Massachusetts, which gave us the state model for what became Obamacare, has the highest healthcare costs in the nation. Further, expanding Medicaid access in Oregon increased utilization of very costly emergency room care, which, we are told repeatedly, is not supposed to happen when people have insurance that promotes access to less expensive forms of primary care.
A young, fit, wealthy President who plays basketball and golf, jogs around the White House in his suit before lunching on first quality food, and lifts weights (sort of), should have drawn much different conclusions about how to improve the health of the American population. What his life of wealth and privilege should have done is prompt introspection about the value of culture to health. Even the people of Mississippi, the country’s poorest, fattest, least fit state, recognize their problem is not medical care, which they use in abundance, but the cultural tools related to health that pass from generation to generation. 
Ironically, this President’s healthcare reform pushes Americans into a kind of medical servitude. His goal should have been to lead people to greater health independence and to say that we want the smallest, most efficient healthcare industry we need to meet our requirements. (Why do political leaders always make that trite, hackneyed statement about the military and never about the healthcare industry?) Instead, he has empowered and promoted bloat, waste, and stupidity. Health reform, as we are seeing it now, is the product of a control-freak mentality because it doesn’t help people see the relative merits of choosing different options and then living with the consequences of their decisions.
Vik The Spartan is pissed at a nation of slovenly couch potatoes who are raising his insurance rates (the PPACA having significantly gutted actuarial risk vetting).
Every administration since President Johnson’s has kicked the can down the road when it comes to fixing the healthcare industry’s many dysfunctions. It was always going to be someone else’s responsibility to make the tough choices. No small surprise, then, that they wrote that philosophy into the law. This is your chance to kick the can back at them and say “No thanks, I think I’ll keep my money and my common sense.” 

Your Personal Affordable Care Act is about avoiding Obamacare and creating a positive health future through the quintessential American values of ingenuity, self-reliance, and gritty, grind-it-out determination. My two best friends describe me as distinguishable not only by my smarts but by my tenacity. I simply will not be defeated. The strategies I outline in this e-book are exactly the same things I teach my executive fitness coaching clients (one of my clients, CEO of a medical technology company, has lost 20% of his starting weight and kept it off for three years, and I’ve never advised him to do anything that isn’t in this e-book), and they are the same things I do (and have done consistently since age 18; I am now nearly 57). Even more importantly, they are what I teach my son, now 10. I know he will follow in my footsteps; in fact, he knows more about good health now than most American adults. (ibid, Kindle Locations 918-927).
You're unlikely to run across the word "humble" in characterizations of Vik Khanna.
In each group of recommendations, I outline things you should know and things you should do, on the belief that knowledge and action are complementary strategies and pointless without one another. My recommendations are presented as a series of points in list format. Each recommendation is brief and to the point. If you want more information to consider or want to review source data, click on the active links. It’s important for you to realize that this is not a debate; I’m not presenting alternative points of view and somehow ensuring mine wins at the end. Mine wins from the start [emphasis mine]. If you choose to be skeptical and want to read the opposition, well, be my guest, Google awaits. Good luck finding all those studies on how eating well, exercising often and as hard as you can, sleeping enough, not smoking, and being a demanding, alert consumer are unproductive. (ibid, Kindle Locations 889-894).
But, who was it who said "it ain't braggin' if you can back it up"?

What about Health IT? The nominal turf of this blog? Not to worry.
Obamacare bizarrely emphasizes technology as a solution to problems that are fundamentally not amenable to technological fixes. We aren’t struggling with population health for a lack of access to healthcare or medical technology. The healthcare industry isn’t expensive and inefficient because of a lack of technology; it’s drowning in technology, such as overhyped and overused diagnostic screenings. The government’s mandate that healthcare providers transition to electronic medical records has created a swamp of miscommunication, failed strategies, and ineptitude that are hidden from the view of most Americans. No one can say with a straight face that your health information is now safer, handled more efficiently, and won’t be used against you by your employer, health plan, or the government. Neither can anyone seriously claim that your physician’s time is any better spent now, fiddling with electronic medical records that frequently don’t’ work as intended, than it was spent dealing with insurance company denials of coverage or reimbursement. 

To demonstrate how deeply embedded the technology fantasy is, consider this: on the weekend of August 18-19 in 2007, I gave a speech at the Maryland Association of Counties meeting in Ocean City. My talk essentially laid out the themes in this book: if we don’t get people to fix themselves and find a way to do that in households, communities, and workplaces throughout the state, there is no hope of containing medical care spending in ways that people will tolerate. In the room for my talk was John Colmers, secretary of the state health department at the time and a long-time darling of the pro-government intrusion crowd. Colmers asked me to comment on his belief that electronic medical records would bring about the long-awaited cost containment and care rationalization revolution. I responded that I was struck by the naiveté of the question, especially in a state where, at the time, small medical practices still dominated the marketplace and likely could not even afford the very uncertain technology he wanted them all to have. Of course, Colmers now works at Johns Hopkins, a temple to modern medical technology which, like many other uber-healthcare institutions, wants to take ever greater control of people’s health lives. 

I do give Colmers credit, however, for not asking the dumbest question of that day in Ocean City. That honor went to the young woman who very earnestly asked when she could expect her health insurer to reimburse her for buying healthier. I asked her if she was acquainted with the phrase “personal responsibility.” (ibid, Kindle Locations 635-656). 
I find "Your Personal Affordable Care Act" a useful, important addition to the health policy literature. It's a real bargain at $4.95 Kindle price (I fussed at him for pricing it so low). I would think the Cato types could afford to buy it in bulk and distribute it to every member of Congress and the Administration and elsewhere in Health Wonkistan. A thousand copies would cost them less than five grand and could pretty much cover the Hill and the White House and the major federal policy analysts.

Maybe we could even comp one to Jonathan Gruber.

BTW, see also
Good luck, Mr. Khanna. I hope it gets national, public traction. Enjoyed reading it very much. Learned some stuff that I will put to good personal use.

This is all I have time for at the moment. My Grandson returns to college tomorrow to finish his junior year at St. Olaf, and I have to take him clothes shopping. If I think of any other material points, I'll update the post.



An old medical joke:
Q: What's the definition of a well person?
A: A patient who hasn't been adequately worked up.
"There is zero evidence that staying fully and relentlessly engaged with the medical care industry will reduce costs or improve health."
Mr. Khanna cites Dr. Thomas Szasz (the "Myth of Mental Illness" guy, whose books I have long had. One of my favorite Szasz-isms was where he railed against the increasing "medicalization" of life itself, wherein we try to assign clinical dx's to every little "problem of living." Szasz then went on to sarcastically posit a curative px he called a "humanectomy."

The U.S. healthcare industry doesn’t just turn the concepts of population health upside down, it simply ignores them, and it worsens many of them by making into medical issues things that don’t inherently require a clinical intervention. This process is called “medicalization,” and its primary purpose is to create dependency on the professions and the institutions they run. Your dependence enhances their status and income. This is not to say there aren’t circumstances that require professional expertise; clearly, people get sick and have accidents and require complex and fast medical management. For these rare circumstances, it’s good to have a highly reactive and well-equipped system. But, people and organizations designed around the concept of fixing are not able to engage in the pursuit of prevention, because it is economically not in their interest to do so, and it is far afield from their core competencies. Medical management simply is not an essential ingredient for just living well. (ibid, Kindle Locations 2487-2497).

The medicalization of our lives has led us to a point where the medical care sector alone is never targeted for down-sizing or even right-sizing. It is trite Washington-insider banter to clamor for a smaller, more effective military, but what of applying this same principle to healthcare? Where is the national challenge to improve ourselves so much that hospitals are forced to downsize or close, and there are as many unemployed doctors as there are unemployed lawyers? Where is the messaging that what we need is a smaller, more efficient, and less error-prone healthcare industry, in which greed is not the core value? Instead of these challenges to change and improve, we are encouraged to drown ourselves in a more-and-bigger-is-better approach to medicine for which there is a 50-year track record of futility. 

Somewhere, Ivan Illich, the radical Catholic theologian who foresaw that the medical care system would one day become our nemesis, is laughing at us. (ibid, Kindle Locations 3154-3164).

"This is not to say there aren’t circumstances that require professional expertise; clearly, people get sick and have accidents and require complex and fast medical management. For these rare circumstances, it’s good to have a highly reactive and well-equipped system." OK, but how much should something like that cost per capita to have around largely on adroit standby for exigent circumstances?

A most difficult question, if you're honest about it. To cite the low hanging fruit analogy, we pretty much don't have private market fire stations. For a reason.

Another good read comes to mind, from my April 9th, 2014 post.


apropos of Vik's fine effort,

I will by no means be the first to note that our medical industry is not really a "system," nor is it predominantly about "health care." It is more aptly described as a patchwork post hoc disease and injury management and remediation enterprise, one that is more or less "systematic" in any true sense only at the clinical level. Beyond that it comprises a confounding perplex of endlessly contending for-profit and not-for-profit entities acting far too often at ruinously expensive cross-purposes...
I wrote those words nearly six years ago on another of my blogs.

BTW: yet another book well worth your time, one that Vik cites and one I've cited before, is Dr. Norton Hadler's "The Citizen Patient."

4. If We Build It, They Will Come
 The Procedures And Devices Gambit 

In this book, I am arming all of us, the Citizen Patients, with the knowledge to demand a health-care system that cannot sell us a pig in a poke, let alone profit from doing so. Americans are enamored of anything that’s new and shiny, particularly if it is “high-tech” and expensive. There are many examples where this fixation has led to progress for some if not all. The Apple Corporation is a case in point. EMI, the British music recording company, turned its attention from recording the Beatles to medical imaging, and now we consider CT scans as ordinary as we once considered routine X-rays. But there are many examples where the newest and shiniest turned out to be useless or a lemon. Such do not survive long in a free market, as the American automobile industry found out.
In the medical world, however, consumerism is gravely compromised. “Caveat emptor” seems irrelevant if something is already indemnified by one’s health -insurance policy. Patients seldom view themselves as consumers. Patients , by definition, are ill and seldom inclined to comparison shop, and even more seldom do they view themselves as purchasing items with which they are familiar from prior purchases. Patients are inherently patsies who depend on the sales pitch of the various providers...

Hadler M.D., Nortin M. (2013-04-01). Citizen Patient (H. Eugene and Lillian Youngs Lehman Series) (p. 91). The University of North Carolina Press. Kindle Edition.  

Someone on LinkedIn doesn't care for me or this post.

"An orgy of simplistic partisan Schadenfreude?" 

Son, look up the meaning of words prior to using them to mischaracterize the efforts of others. What part of "I find "Your Personal Affordable Care Act" a useful, important addition to the health policy literature" do you fail to comprehend?

More to come...

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