1. People who are not taking care of themselves should get less money.
-If you have a condition that requires you to maintain a certain sort of diet, quit smoking or get a certain amount of exercise, you have X amount of time to meet these requirements. If you do not meet these requirements and your doctor doesn't sign a medical waiver* for you, then the percentage of treatment the government will pay for on that condition starts to taper off. Once you meet the requirements, it jumps back up to its previous level.
It should be noted that this proposal is not saying you can't smoke, it is saying that if you don't quit under doctor's orders you might have to pay for your own healthcare for smoking related illnesses. Yes, it's kinda Nanny State, but I don't see it as less so than government-sponsored healthcare in the first place.
-The Government should collect data on how much it costs to treat the average person who was in a car accident and wearing their seatbelt on a hospital-by-hospital basis. Those who were in car accidents and not wearing their seatbelts will be covered for the amount that the government paid the average seatbelt-wearer at their hospital and beyond that are on their own. This could be applied to other stuff, but seatbelt-wearing is the most straightforward.
2. The "I'm ready" form.
A patient may at any time request a simple "I'm ready form" that all hospitals will keep around. After they have signed that form, no treatment will be covered by the government excepting pain relief. If said patient is at a hospital that is committed to fighting and fighting for patients' lives and putting their patients through operations and such to extend life by small amounts of time, they do so at their own expense once the form is signed. "No, wait I'm not" forms rescinding the previous forms would, of course, also be available.
The last two people I've known well who died eventually got to where they wanted to give up and go die at home. Both of them got their wishes because they had forceful personalities and supportive families. We might as well have the form for those people who have neither, but have the same wish. (Item: Most of the rise in healthcare costs has been from Medicare. One third of Medicare bills are from patients who live for less than two years after the treatment.)
I can see lots of disadvantages to these ideas, but I can see advantages too. Comments?
*Some people in wheelchairs, for example, are skinny. But many are not because it's hard to maintain a healthy weight when you don't even walk. If losing weight is a requirement and someone in a wheelchair is having trouble doing that, I'm willing to exempt them if their doctor is.
23 comments:
The requirements that are just passive cessations (stop smoking, stop drinking, etc.) probably are more workable than those that require people to begin doing something actively.
-If you have a condition that requires you to maintain a certain sort of diet, quit smoking or get a certain amount of exercise, you have X amount of time to meet these requirements. If you do not meet these requirements and your doctor doesn't sign a medical waiver* for you, then the percentage of treatment the government will pay for on that condition starts to taper off. Once you meet the requirements, it jumps back up to its previous level.
If you are putting obesity in here, you are going to get huge (and not wholly unreasonable) pushback from advocates on behalf of the obese. First, how are we doing to define obesity? Going simply by weight doesn't work; obesity is medically defined by the level of fat in someone's body. I am in the "normal" weight range, but I've had cholesterol in the danger zone since I was 11. Combination of insufficient cardiac exercise, diet, and bad genes. Diet can change my cholesterol without your seeing any change in my weight, although if you looked closely while I was wearing tight clothes, you might be able to discern whether I was carrying more fat or muscle.
Second, doctors live in the same obesity-loathing culture as the rest of us, and sometimes over-attribute symptoms to weight. People who are seriously overweight can tell you stories about doctors who simply refuse to treat them until they lose weight. The fact that this weight may be almost impossible to lose due to factors not based on cheesecake consumption and trips to the gym (e.g. apparently a lot of psychotropic drugs cause weight gain) doesn't always change the doctor's mind.
I'd strongly recommend that if your suggestion became law, medical schools begin mandating education on what science definitely has deemed "obesity caused" and what is still speculative, and that doctors who don't provide a waiver for anyone whose condition is not in the "definitive causation" category be prima facie liable for malpractice. Human biology is not as far advanced as you may believe... for example, they're now teaching in medical schools that the mechanism by which obesity causes diabetes is that abdominal fat can "dull" insulin receptors, thus forcing the body to produce more insulin in order to get through to the receptor, and eventually exhausting the body's ability to produce enough insulin and causing Type II diabetes. But that's just the current theory. Doctors have discarded theories in the past, including the one about how estrogen replacement therapy was good for all post-menopausal women.
PG is right. I weigh as much as two people, but my chloesterol, triglycerides, fasting blood sugar, blood pressure, resting pulse are all fine. It actually seems to upset the younger doctors.
Comments and questions. First for #2 - what would prevent the "Our hippy family wants to use wheat grass enema treatments instead" or "we will just pray for a cure" folks from using these forms? Is it a problem if they do? What sort of language would be needed to offer the form?
#1 - In general I don't like the idea because it seems to encourage people to be even more irresponsible. If you smoke a few packs a day until you need the iron lung, and never visit the doc in the meantime, then you get full coverage. No one ever told you to quit. The person that smokes just as much, but goes to the doctor for other preventative treatment, gets hosed. generally speaking proposals that make low cost preventative treatment cheaper are better. Like 24x7 nurse practitioner care at WalMart for free. Keeps folks out of the ER for their basic health care.
Why not just go for the "sin tax". Tack a $5/pack tax on cigarettes and have people finance their iron lungs.
While we are at it we could get the government to stop encouraging unhealthy behavior. Take the subsidies away that encourage manufacturers to use corn syrup (sugar) as a preservative, and the subsidies that make sugar so cheap that you can give packs away for free and give those subsidies to people to grow vegetables. Make it so you can give healthy veggies away for pretty much free. Much more straight forward than getting the lawyers involved on the clinical diagnosis and if someone has maintained a healthy lifestyle.
If I don't wear a seat belt, but the accident is not my fault, then how much liability do I get?
Generally speaking I am not sure that seat belt and motor cycle riders without helmets make up a huge chunk of health care costs.
In general I actually like the idea of penalizing unhealthy behavior, but I think the method you propose could make things worse. Especially since inevitably the wealthy would be able to afford the method to maintain coverage (favorable hospitals, good lawyers, etc.) and others would not. I suspect you would penalize those least able to afford it.
PG
You're right about the cessations, but I figured fat people were sufficiently culturally despised that the law couldn't pass without including them.
I agree with your proposed modifications. I was figuring there would be a national standard of when this rule could be invoked.
Uupdater
The "I'm ready" form would only be available to those over 18. If someone over 18 wants to cure her cancer with wheatgrass enemas, I'm not arguing.
I totally don't mind the free preventative care nurse idea.
I don't see the smoking issue working that way because almost nothing is cured with one big treatment at the end.
If the accident isn't your fault you get whatever you can get out of the guy who hit you.
You might enjoy this article:
http://www.theatlantic.com/doc/200909/health-care/
which I've been chewing on for most of the day -- a lot of it makes sense, but I hate to think about health care in a consumerist mindset and would rather that patients never have to worry about the monetary side of their care. No idea how to ever make that happen, but it's my personal ideal.
I don't think this quite works. No one would argue that you shouldn't get treatment for anorexia because all you really need to do is eat a cheeseburger.
Other problems: Would you propose to do anything about sports/exercise related injuries? (You won't pay for my anti-cholesterol drug, but I have to pay for your knee replacement?)What about sexually transmitted and other communicable diseases? Other kinds of accidents?
((((I don't think this quite works. No one would argue that you shouldn't get treatment for anorexia because all you really need to do is eat a cheeseburger.)))
No, they wouldn't. Using standards developed be actual doctors was the plan and I don't think "Go eat a cheeseburger" is a recognized treatment regimen for anorexia.
Also, I don't know that this plan would work well for mental illnesses at all given that setbacks are a part of mental illness.
I was really thinking of it more toward someone getting expensive treatment for respiratory problems, yet won't even try to cut back on his smoking.
(((Would you propose to do anything about sports/exercise related injuries? (You won't pay for my anti-cholesterol drug, but I have to pay for your knee replacement?)))
Was the person who is getting the knee replacement told by a doctor that his jogging was damaging his knees and to stop? Did he keep jogging anyway? If so, he pays for his own knee replacement, or at least the government pays for less of it.
If it's an old guy who has taken care of himself but needs a new knee because he is old, his knee replacement would be covered.
And the only people who WON'T have their cholesterol medications covered are those who have been told how to minimize their high cholesterol on their own and have chosen not to follow the advice and cannot convince their doctors that they had a legitimate reason for not following the advice.*
An alternative would be to require adults who engage in high-risk activities to get an umbrella policy where they pay the government x amount more and are covered for activities that the government might not cover otherwise. Don't know about that one, though.
(((What about sexually transmitted and other communicable diseases? )))
Since one can be perfectly careful and still get those (in the case of STDs I'm thinking of cheating spouses and mouth sores) I would say that they should be fully covered.
(((Other kinds of accidents?)))
Smarter people than me would have to make the distinctions between truly negligent behavior and ordinary imperfection.
In my previous job, we dealt with construction workers who were hit by falling debris because they were in the wrong place at the wrong time and we dealt with construction workers who fell off a beam 20 feet above the ground because they just hadn't put on their required safety harness. Workers Compensation law treats those two cases differently. Can't see why national health insurance shouldn't do so as well.
CC
*"Doctor, I know I should be doing more walking for my cholesterol, but my orthopedist told me I should stay off my knee"
"Well, I wish you'd called my office before now, but here's your waiver and here's a list of exercises that don't involve your knees. I still want you exercising for 20 minutes a day three times a week. We will keep up your cholesterol medication for now and talk again in three months. Oh, and how have you been eating?"
is how I envision this typically happening.
I confidently predict that the bureaucratic cost of micro-managing and rationing care in this way would quickly exceed any cost benefit--and create a whole new revenue stream for hoards of lawyers.
(((create a whole new revenue stream for hoards of lawyers.)))
Yay!
But seriously...
For those of you who are so against this idea, I ask:
1. Do you deny that how you take care of yourself is a strong component of health care and that people not taking care of themselves costs lots and lots of money on a national level?
2. Or do you not deny that and think that people who do take care of themselves and are willing to sacrifice by getting up a little earlier to walk, or eating more veggies or giving up whatever people get out of smoking should be subsidizing those unwilling to make those choices?
Again, we all know that there are situations where people have excellent reasons for not taking care of themselves. I'm fully willing to exempt those people.
But I think we also know that a huge majority of this country would be healthier if they drank less soda, smoked less and walked more and those little changes from people who needed to make them would make Universal Health care FAR less expensive.
Is this all so unreasonable?
CC
not a paragon of virtue, at all, in the "taking care of herself" department and aware that she is proposing something that might well bite her in the ass someday, but also thinking that this is the right thing to do.
(Also, I don't know that this plan would work well for mental illnesses at all given that setbacks are a part of mental illness.)
But smoking in many cases is an addiction which is a mental as well as physical illness. Same with Obesity and anorexia.
And what about people who have high muscle, like body builders, firefighters, soldiers, who have low body fat percentage but high BMI. What criteria do we use? How about low BMI, low body fat percentage people who still have dangerous lipid panels? or the reverse; people who have high body fat and BMI but show normal lipid panels, liver function, and insulin response?
Then look at the umbrella policies for high risk people. Should professional athletes have to buy them because they are at higher risk of orthopedic injury? What about firefighters? Hazmat remediation workers? I don't think we should have financial disincentives for people who choose to do the difficult and dangerous jobs that society can't function without.
With a plan like this you start making moral judgments about about people and their ability or lack of ability to mentally control their physical characteristics.
I think a better plan would be to use the model that the UK has and put doctors on salary rather than fee for service and then give doctors/doctor groups bonuses for how well they get their patients to follow advice and correct dangerous behaviors.
The only patient based penalty I think would be viable would be for not showing up for your annual physical or other suggested follow-up care.
I'm not sure why people keep assuming that healthy but chubby people whose weight was in no way contributing to any condition would be subject to any issues under this plan.
The government can't not pay for the treatment of a condition that doesn't exist. So I don't think the conclusion that healthy but chubby people would be penalized follows logically from anything I've said.
I've never even brought up BMI.
I don't know that I view smoking as a "mental illness" in the sense that anorexia is. I'm not saying that quitting smoking isn't difficult but people do it all the time and it is a no-brainer for the government to provide the smoking-cessation help that some health insurers already provide.
Within very few decades, we will be at a point where very few living people will be able to claim that they had no idea that tobacco was dangerous when they started smoking. Scientists knew tobacco was dangerous in the 30's, but I'm willing to take a more liberal date and say that if you started smoking after Reader's Digest* wrote about the dangers of smoking in 1957, you knew damn well that what you were doing was dangerous and addictive. If you were 15 in 1956, then you're 68 now. Younger people damn well knew what they were getting into and if they've chosen not to get out of it, then the expensive cigarette related health problems that result shouldn't all be on the taxpayers' dime.
Should the people who do quit smoking or were smart enough not to have ever started have to pay for the additional heart attacks, strokes and cancers of the people who don't? I'm not sure why not.
(((Should professional athletes have to buy them because they are at higher risk of orthopedic injury? What about firefighters? Hazmat remediation workers?)))
Every single one of those activities is a job and presumably those employers are providing health insurance now. Health insurers aren't stupid and know damn well to charge the employers of accountants less than the employers of Hazmat workers. Those employers will save TONS of money should the system switch to a health care system propped up by the government. Let the employers pay the umbrella policy with some of that savings.
(((With a plan like this you start making moral judgments about about people and their ability or lack of ability to mentally control their physical characteristics.)))
Their lifespan and the cost to treat their medical problems would seem to make that judgment for me, IMHO.
I'm not inventing the idea that smokers die expensively.
((( then give doctors/doctor groups bonuses for how well they get their patients to follow advice and correct dangerous behaviors.)))
Thus giving doctors an incentive to chase away irresponsible patients since they will make more money treating responsible ones?
Geez, at least my plan gives the incentive for positive life changes to the patient.
CC
*MANY journals, magazines and newspapers had written about it well before then, of course. Reader's Digest not being an exactly groundbreaking publication, they seem as good a measure as anything of when the average person would likely have known something as my impression is that by the time something is written up in Reader's Digest, most people who are paying attention have known it for awhile.
I'm not inventing the idea that smokers die expensively.
There's actually been a lot of skepticism that smokers die expensively relative to people with other conditions. Lung cancer tends to wipe people out with convenient speed. If all I cared about was how much I'd be spending on someone's health care -- not on the cost-benefit analysis of how many years I extended her life -- I'd totally take the smoker with lung cancer over someone with breast cancer. Lung cancer lady is almost certainly dead quite quickly, not to mention at a convenient age for society (the diseases most directly related to smoking tend to crop up toward the end of someone's working life and beginning of retirement age, thus leaving more in the Social Security kitty for the rest of us).
When U.S. cigarette manufacturers were finally able to sell in Eastern Europe after the end of the Cold War, they actually tried to promote smoking to these governments (which were retaining their responsibility for covering health care, even after the end of communism) on the grounds that, sure, it would kill some people, but at such a convenient time and so cheaply! Meanwhile, the governments could collect lots of sin tax revenues in the cigarettes, because smoking is bad.
Breast cancer lady is probably still in her 30s or 40s, has to get surgery and chemo and prosthetic boobs and mammogrammed twice a year for the next decade and then it comes back and you do it all over again... if I don't care about saving lives, just about saving money, I'm handing breast cancer lady a truckload of cigarettes.
(((I don't know that I view smoking as a "mental illness" in the sense that anorexia is. I'm not saying that quitting smoking isn't difficult but people do it all the time and it is a no-brainer for the government to provide the smoking-cessation help that some health insurers already provide.)))
You just helped make my point. You have made a moral judgment about people who can't stop smoking. It is a mental illness according to the DSM-IV: 305.10 Nicotine dependence. Different people have different responses to drugs like nicotine. Some get physically/psychologically addicted after one use, some can start and stop whenever they want. Legislating complex, individual, biological systems and/or moral issues is near impossible and should be avoided at all costs, IMHO.
(((If you were 15 in 1956, then you're 68 now. Younger people damn well knew what they were getting into and if they've chosen not to get out of it, then the expensive cigarette related health problems that result shouldn't all be on the taxpayers' dime.)))
Again, a moral judgement. Can we take extenuating circumstances into account here? Did the child have parents who smoked? Did they grow up in a Tobacco culture (some of my friends from Kentucky got their spending money from their own family tobacco plots)? Should people who live in areas where smoking is banned in restaurants face a higher penalty because they aren't exposed to a culture of smoking?
(((Every single one of those activities is a job and presumably those employers are providing health insurance now.)))
As a small business owner, I hate the fact that business owners are on the hook for health insurance. Why should I have to pay for that other than it has been done that way since WWII? I have no problem with workers compensation to pay for work related injury, but general health for employees and theirs families? That should be the responsibility of the individual or the Government, not mine.
I've heard Canadian business people talking about how wonderful the US system is because we have to have those extra costs on the books and they don't because it is covered by the Government. That's the best argument for single-payer I've ever heard.
(((I'm not inventing the idea that smokers die expensively. )))
Certainly not and it is a known fact. The issue here is how to best modify behavior. I think a system that makes a moral judgment that every person can stop a destructive behaviors and penalizes those who fail, possibly with their life and/or the financial security of their family, is not the right thing for our country.
(((Thus giving doctors an incentive to chase away irresponsible patients since they will make more money treating responsible ones?)))
I've not heard of this happening in the UK where they have a system like this. I'd welcome any reports that you can find that show this to be the case.
(((There's actually been a lot of skepticism that smokers die expensively relative to people with other conditions. Lung cancer tends to wipe people out with convenient speed.)))
But you still have to consider COPD, heart attack and stroke which all have the potential to be expensive long term conditions.
But I love the rest of the post. You gotta love the logic of the tobacco companies.
(((. It is a mental illness according to the DSM-IV: 305.10 Nicotine dependence. Different people have different responses to drugs like nicotine. Some get physically/psychologically addicted after one use, some can start and stop whenever they want.)))
If someone's addiction is this severe, then I would think that would be evident to a psychologist, who could get them a waiver after having them try a few methods of quitting.
(((Did the child have parents who smoked? Did they grow up in a Tobacco culture (some of my friends from Kentucky got their spending money from their own family tobacco plots)? Should people who live in areas where smoking is banned in restaurants face a higher penalty because they aren't exposed to a culture of smoking?)))
Umm... some people grew up with Dads who beat their wives, in a culture where wifebeating was overlooked and where they might be exposed to the neighbor's wife being beaten.
We don't hesitate to disincentivize spousal abuse because we expect people to know damn well that it's wrong.
We already disincentivize smoking with tobacco taxes. If smokers are willing to pay taxes, why not ask them to save up for their eventual lung cancer treatments rather than asking the rest of us to pay?
(((Why should I have to pay for that other than it has been done that way since WWII? I have no problem with workers compensation to pay for work related injury, but general health for employees and theirs families? That should be the responsibility of the individual or the Government, not mine. )))
I'm not asking you to pay for 'general health' at all. I only said that if we had a special umbrella policy for people in high risk jobs, employers of those people might cover it.
Assuming the workers' comp system was kept in place, they might not even need to do that. However, if the government is running all of healthcare, then the workers' comp system might not be necessary.
((( I think a system that makes a moral judgment that every person can stop a destructive behaviors and penalizes those who fail, possibly with their life and/or the financial security of their family, `is not the right thing for our country.)))
Then you also favor revising the entire tax code for the country as incentivizing things and disincentivizing things is a huge part of the way our tax system is put together.
(((You gotta love the logic of the tobacco companies.))
You're the one trying to help them stay in business.
CC
Oh, and British doctors are on my side:
http://www.telegraph.co.uk/news/uknews/1576704/Dont-treat-the-old-and-unhealthy-say-doctors.html
(((If someone's addiction is this severe, then I would think that would be evident to a psychologist, who could get them a waiver after having them try a few methods of quitting.)))
Does a poor person have the ability to shop around for the doctor who will grant them a waiver? There are entire states where women cannot get an abortion to save their life, would this system be just as likely to suffer from doctors who have political agendas to deny waivers?
(((Then you also favor revising the entire tax code for the country as incentivizing things and disincentivizing things is a huge part of the way our tax system is put together.)))
No, I'm just saying that the way you have suggest structuring the incentive/disincentive is at the wrong place. If the disincentive is implemented when someone needs health care, it's too late for it to work. The proper place is to apply sin taxes where the revenue can be stashed away and used for those patients if/when they need it. The disincentive is in your face and if you don't care or cannot change, at least you are paying for your future care.
(((You're the one trying to help them stay in business.)))
That's simply not fair. Enough said on that.
(((Oh, and British doctors are on my side)))
Actually, only 522 of 870 surveyed are on your side. The article doesn't report the margin of error of the survey, but 870 is about 0.4% of the doctors in the UK. If I've done my math right, the margin of error is +/- 28 points. So even though the 60% sounds terrible, it doesn't seem like a good survey. And that assumes that the sample is perfectly random, which I don't know. What we can say is that "...the British Medical Association and campaign groups describing the recommendations from family and hospital doctors as 'outrageous' and 'disgraceful'."
How far would you carry this principle? Poverty and homelessness can be the results of bad decision making, too. Would we tie poor relief to lifestyle choices?
(((Does a poor person have the ability to shop around for the doctor who will grant them a waiver?)))
I would think so. After all, that the poor will be able to afford medical care is the general gist of the larger discussion.
But I would question whether "shopping around" for a doctor who would grant them a waiver immediately is a good idea. If a person's smoking is killing him, then if I were that person, I'd pick one psychologist or doctor and try the methods that they suggest, even if those methods have failed in the past.
I know someone who tried to quit with the patch twice on her own and failed, then tried while on anti-anxiety drugs prescribed by a doctor who supervised her attempt to quit and she was able to do it. Once she'd been off cigarettes for awhile, she quit the anxiety meds and has been smoke free for not quite ten years.
My guess is that most smokers who think they can't possibly quit have never tried to do so under a doctor's supervision since that would be somewhat expensive under lots of insurance plans. If we had universal healthcare, they could give it a shot. I honestly don't see a downside to trying.
Most smokers have to try at least a few times to quit, so who knows? A physician supervised program might work. Best case, they manage to do quit and the issue is moot. Worst case, they get the waiver honestly without having to "shop for it."
((( would this system be just as likely to suffer from doctors who have political agendas to deny waivers?)))
A political agenda for a doctor to deny a waiver to someone who tries to quit smoking under said doctor's supervision and yet repeatedly fails does not seem likely.
If anything, it would work the opposite way as meeting with a patient for five minutes and signing a waiver stating that the patient has worked hard to quit and just can't, and meeting with a patient for an hour to work out a smoking cessation program, would probably pay the doctor about the same.
So, yes, those people who were determined to cheat the system and get the waiver without actually trying to quit smoking would probably be able to.
(((The proper place is to apply sin taxes where the revenue can be stashed away and used for those patients if/when they need it. The disincentive is in your face and if you don't care or cannot change, at least you are paying for your future care.))
This is funny because like the first five objections people had to this proposal involved ALL fat people being ordered to loose weight rather than just the ones whose weight was making them sick.
Now your suggestion is to make ALL smokers pay, NOT just the ones whose smoking is making them sick.
Can't win for losing on this blog.
((( So even though the 60% sounds terrible, it doesn't seem like a good survey. )))
I'd think most people doing surveys would kill to get .4% of the entire population they were studying. And I would think that the British Medical Association would point out any obvious flaws in the methodology rather than merely decrying the results if such flaws existed.
And in truth, a lot of those doctors were more radical than I am. Provided the old want to be treated, I don't mind treating the old at all as old age is not related to personal responsibility.
I am with the doctors, however, on the liver patient.
If there is a liver patient who refuses to stop drinking, should he or she be given a transplant liver that could go to someone else?
Should money be used to pay for that operation that could be used to pay for healthcare for someone else?
CC
(((How far would you carry this principle? Poverty and homelessness can be the results of bad decision making, too Would we tie poor relief to lifestyle choices?)))
You don't think they are tied that way already?
You don't think that people who are demonstrably trying to get job skills or a degree, educate their kids, find a job and get off the street get a lot more relief and help than those who appear content to just let the bad lifestyle choices run their course?
I'm mostly playing with this idea as a cost-containment idea for public health care, but it's pretty much in practice everywhere as far as I can tell.
CC
2. Or do you not deny that and think that people who do take care of themselves and are willing to sacrifice by getting up a little earlier to walk, or eating more veggies or giving up whatever people get out of smoking should be subsidizing those unwilling to make those choices?
This.
Mark,
Fair enough.
Out of curiosity, where are you on the questions about the liver patient that I asked in my response to Dancin' Hippie?
CC
Every day at my crummy retail job I see coworkers smoking, eating junk food, swigging sodas and coffee like crazy. Yes, there are others of us who eschew these pleasures, but for many, likfe never seems to have given them a chance to reframe their brains around other goodies. On the contrary, what I call a "crummy retail job" to them has represented success -- getting off welfare, etc.
As much as I hate the quick pick-me-ups they choose to use, I have to admit from working with them that the crummy retail jobs, whether you got there from a rung above or below, don't pay enough to work on self-fulfillment at another pace. Not interesting vacations. And yes, even I often come home too tired to anything but junk tv. Forget requiring the gym two or three times a week for someone who just spent eight hours on their feet at work.
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