OP-ED

My Personal Affordable Care Act–A Manifesto

The Founding Fathers had one.  Karl Marx had one.  Bertrand Russell and Albert Einstein had one.  And, now I have one: a manifesto, declaring my intent to live my life with as little interaction as possible with the US health care system by doing what the Affordable Care Act (ACA) tells me by omission I do not need to do: take responsibility for myself.

This is my Personal Affordable Care Act.

My manifesto is an algorithm for thriving in spite of the government’s naked and absurd attempt to define health as something that begins in the clinic.  My goal is to make myself and my family as scarce as possible within the health care system.

The ACA is a collective solution to the mass failure of individual will.  Our transformation into an information culture actually worsened the malady.  We are so conditioned to success at the speed of a search engine that, like the person who aspires to retire early, but refuses to save, we’ve forgotten to manage the fundamentals.

First, that every healthy lifestyle decision you make today, from diet and exercise to outlook and mood, requires thought and an exertion of will.  Even in the age of Google, volition matters, and choosing not just wisely, but strategically, is an option available to most people.

Second, despite revolutionary democratization of medical information, we still don’t do our homework.  Americans visit physicians 3 times per year on average, and the number one reason for the visits is “cough.”  Really?  You need to go to the doctor for a cough?  Unless you have a fever, chest discomfort, bloody sputum, or the cough lasts for weeks and keeps you up at night, it is almost certainly viral or related to an allergen and self-limited.


It’ll get better soon; try an over-the-counter remedy.  Drink some tea with honey.  And, stop badgering your doctor to give you an antibiotic for something that isn’t bacterial, because that particularly lame demand is responsible for the emergence of antibiotic-resistant superbugs.

The second most common reason for physician visits is backache, for which the leading the contributory factor is a bulging panniculus…or big gut.

Third is our expectation that someone else will fix the problem for us.  Your physician cannot fix your bulging panniculus.  Only you can and when you do, even if only a little, you’ll have the richest reward of all…the sense of accomplishment that comes from personal betterment.  We’ve spent so much time and energy waiting for someone else to do the work that we’re disconnected from the fact that the dilemma started with each one of us.  My parents may not have had much, but they had the dignity of doing everything they could for and by themselves, before they held their hands out for help.

To that end, I hereby resolve to:

  1. Admit the obvious. To paraphrase 12-step-self-help programs, the first step in solving a problem is admitting you have one, or, in this case, that we have met the enemy and it is us.  It is simply inconceivable that if we were a lean, fit, nonsmoking culture with clarity about the distribution of risk and cost impacts that we would have ended up with the ACA or any of its derivative shenanigans.  Instead of getting the health care system that we all think we deserve, what we got is our just desserts, in part because we spend too much time eating dessert…in front of the TV…and then sneaking out for a smoke during timeouts.

  2. Lead my family by example. I will use meals, car rides, and games of catch as opportunities to teach my son the real facts of life…that the person you become derives largely from the choices you make every day.  If you choose to consume detritus (caloric and cultural), smoke, drink to excess, refrain from exercise, and treat knowledge and love with nonchalance, then you end up looking and acting like someone who’s excelled at those things.  Look around you.  We’re great at it.

  3. Use technology smartly, but not obsessively. Most apps are for the motivated like me.  They’re toys.  The app that tracks a run is trivial compared to the run itself and no app will get you to move.  That comes from somewhere deep inside.  The apps I love are LoseIt.com, a diet tracker I use to help restrain my affection for snacks and Scotch, and Strava for aerobic exercise.

  4. Leverage preventive medicine that works (i.e., age- and situation-specific vaccinations, colonoscopy every 10 years after age 50, blood lipid screening every 5 years, and checking my blood pressure periodically when I am in Walgreens; many other preventive recommendations are physician-patient discussion items, such as whether to take aspirin daily), but I will not be seduced by the far greater amount that doesn’t, which has much more to do with excess capacity in the medical care system than it does clinical sense.  I know from nearly 30 years in this business that to most health care system administrators, I am a reimbursable data point and nothing else.  Just another cog in their unquenchable drive to “optimize payer mix” and “maximize reimbursement.”

  5. Stick with physicians I like, trust, and can communicate with, not because I want their love and devotion, but because everyone needs a good fixer. Stellar strategy or not, health is unpredictable and acute events will still happen (which is why you carry insurance).  When they do, I want a fixer who fixes and then leaves me alone.

  6. Use social media to drop the hammer on health plans, health systems and medical care providers who don’t meet my customer service expectations. We spend too much time twiddling our thumbs about quality reporting.  I’ve got some quality reporting for you: treat me or my family rudely or incompetently, and I will light you up Twitter, Facebook, Google+, and everywhere else I can think of.  Too bad that when Josie King was dying in Johns Hopkins Hospital, social media was not the force that it is today.  Health care entities need to remember that they are vendors to the rest of us.  It’s also useful to remember that the privacy laws only work one way: I can disclose anything I want about the quality of a health care interaction I’ve had to anyone I please and, as long as I don’t defame, slander, or libel, I cannot be stifled.  They, on the other hand, open themselves up to enforcement actions and civil liability if they disclose personal health information about me.

  7. Use the American Heart Association’s standards of ideal cardiovascular health as my benchmarks, because adults who have all seven have a 63% lower death rate than adults who have zero.  The seven are: normal weight; regular exercise; high quality, plant-rich diet; no smoking; normal blood lipids, blood sugar, and blood pressure.

  8. Know as much about myself as possible, so that if I start slipping in one measure or another, it will register with me, thus, prompting me to take corrective action.  I will know my waist measurement, my waist to height ratio, how fast I can run a mile, how many pushups I can do, how well I eat every single day, and my resting heart rate, which I will aim to keep below 60 bpm.

  9. Keep my emotional and spiritual center through regular meditation and prayer, because health is not all about the body, and, at any rate, these things may help improve some cardiometabolic markers.

And I will to do all this even though the government’s underwriting restrictions for health insurance premiums establish contrived parameters of only age, family composition, smoking, and geographic area.  Hence, my strategy will earn me nothing because the premiums I pay will not reflect my diligence but largely the habits of people living around me which, in Missouri, the land of toasted ravioli and creamery custard, is not a happy prospect.  This is, of course, a stark contrast to every other form of insurance in the known universe.

Trying getting auto insurance after you’ve had a DUI conviction or homeowner’s insurance if you refuse to put a fence around your pool.  You pay dearly for those choices.  My payoff will be what it has been for the last 30+ years…I pay almost nothing in the form of copays and deductibles each year, because I don’t use the system.  But, other than that, the system will not reward my personal effort, even though my work sets me far apart from the rest of the populace.

Here is something that I will not do: I will not break the law, which requires me to have health insurance, and I will not advocate that it be defunded or otherwise delayed.

I am a nonpartisan conservative, and I am appalled at the machinations in Washington.  Not only was the conservative Heritage Foundation the fire starter for the individual mandates that eventually emerged in both RomneyCare and the ACA, conservatives who now strong arm the administration are running roughshod over a core conservative principle: you play by the rules.

You don’t like the rules?  Maybe field Presidential candidates that don’t repulse half the country, and you’ll win elections so that you can write the rules.  Not that winning elections has mattered before.  If conservatives had made meaningful health care market fixes during the, oh, twenty years they held the White House after 1980, then the ACA likely never happens.  Instead, it’s been legislated and adjudicated.  Get over it.

Conservative opposition to the ACA relies primarily on the strategy of small-minded petulance and, remarkably, overlooks that even bedrock, everyday middle-America conservatives might find it a lifesaver, because most of us aren’t earning a 7-figure living whoring ourselves (or pining to do so) on K Street.  Second, conservatives needed to let the entire ACA play out without obstruction.

If it fails, then you make its failure the everlasting legacy of this President, Vice President and Congress.  Of course, you also end up with a mandate for change, and, well, see above for how deftly you’ve handled that responsibility before.  But…if it works, then you cheer for the good of the country.  And, in my stripe of conservatism, what’s good for the country comes first even if it isn’t my political cup of tea.

Patriotism before politics and petulance.  Instead, conservatives have made a weak President seem strong, and are losing votes every single day from people who might have been open to calls for incremental alterations.

The conservative message on the ACA is incoherent and its messengers are dolts whose leadership skill set is as desolate as the lunar landscape.  My conservative, take-responsibility-first approach will not relieve me of the need to carry and pay for health insurance, something I’ve done my entire life anyway.  But, it will minimize as much as is humanly possible the amount of time and treasure my family or I will expend dealing with doctors, hospitals, health plans, and their dimwitted cousins, the wellness vendors.

And, when I do deal with them, it will be on my terms, not theirs.

Vik Khanna is a St. Louis-based independent health consultant with extensive experience in managed care and wellness.  An iconoclast to the core, he is the author of the Khanna On Health Blog.  He is also the Wellness Editor-At-Large for THCB.

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