Newshoggers.com

HCR -- Binge Drinking and Other Challenges

By John Ballard

►According to the CDC about one in six adults binges on alcohol. 
The number of drinks averages eight.
The average frequency is weekly.

Binge drinking -- defined as at least four drinks in one sitting for women and five drinks for men -- carries substantial risks and high costs. It accounts for more than half of the estimated 80,000 annual deaths and three-quarters of the $223.5 billion in economic costs tied to excessive alcohol use.

In addition, it is associated with a greater risk of a multitude of problems, including car crashes, violence, suicide, hypertension, acute MI, sexually transmitted diseases, unintended pregnancy, fetal alcohol syndrome, and sudden infant death syndrome (SIDS).

Details at the link. 
I could type reams of commentary but the reader can furnish his own. Anyone who thinks this is not seriously related to the health care debate, public health, politics and the economy is advised not to help any children with coloring books, especially the kind involving connecting the dots.  

►The death of a loved one increases the risk of heart attack for survivors. 

Among a cohort of 1,985 people, the rate of myocardial infarction was more than 21 times higher than normal within 24 hours of losing a loved one, reported Murray A. Mittleman, MD, DrPH, from Beth Israel Deaconess Medical Center in Boston, and colleagues

The absolute risk of experiencing an MI within a week of a significant loss was higher for those already at a high 10-year risk of MI: one per 320 versus one per 1,394 for those with a low 10-year risk, according to the study published online in Circulation: Journal of the American Heart Association.

~~~~~~~~~~~

During the first week of bereavement, the risk was almost six times higher than normal. Although the risk declined each day after the death, it remained significantly elevated for at least one month following the loss.

Researchers found that men were more sensitive to negative health consequences from bereavement than women and younger people, more so than older bereaved people, which is consistent with other findings, they said.

A number of psychological stressors are associated with bereavement including anger, anxiety, and depression. In addition, those mourning the loss of a loved one could have reduced appetite, reduced sleep, and inadequate medication compliance.

"Caretakers, healthcare providers, and the bereaved themselves need to recognize they are in a period of heightened risk in the days and weeks after hearing of someone close dying," Mittleman said in a statement.

►Educate patients when it comes to cancer screening tests

This is old news for regular readers, but repetition and reminders are never a mistake. Like so much important information this has no money-making advocates so the only way to spread the word is word-of-mouth. 

• women in their 40s do not appear to benefit from mammograms 
• women ages 50 to 74 should consider having them every two years instead of yearly
• also recommended that routine colonoscopy not be done for screening purposes in patients older than 75. 
• This year it was recommended that pap smears begin at age 21 and be conducted at least every three years 
• P.S.A. tests for prostate cancer detection not be performed on a routine basis.

►How can we train more geriatricians?

I have a 90-year-old father and an 86-year-old mother who are still living independently but are very frail. Thirty years ago, when I graduated from medical school, they were sprightly at ages 60 and 56. Back then, I didn’t appreciate the importance of geriatrics. Boy, I do now.

I have learned some valuable lessons while helping to manage their care.

A great doctor knows what not to do as well as what to do. My parents are lucky to have a great internist who has been their physician for 35 years. He knows the importance of not doing everything. He has tried to find the right balance between intervention and observation. Not everything needs to be fixed.

Avoiding hospital stays is critical. After age 85, people don’t get better when they are admitted to the hospital; they get worse. They get loss of muscle strength from prolonged bed rest with no PT, pressure sores, new confusing medications, and antibiotic destruction of their gut flora that results in embarrassing diarrhea. I tell my dad that he is like a shark: “If you are not moving, you are dying.” Continued activity is the key to independence. Until nine months ago, even though he is blind, my dad walked on his treadmill for 20 minutes a day. Although only 1.2 miles an hour, he was moving.

Nurses in most community hospitals don’t really know how to care for elderly people. Seeing an untouched meal tray, they say, “I guess you weren’t hungry,” and take it away. It doesn’t occur to them that elderly people often can’t hear or see well enough to navigate the complexities of feeding themselves when hospitalized. My family makes sure one of us is parked in my father’s room most of the day; we schedule family members to be present at every meal to help my father eat.

Medicare is a fabulous safety net that allows many older people to age in place in their homes. It provides hospital beds, lifts, oxygen concentrators, and weekly home health nurse visits. This is why my parents have been able to stay independent.

There are angels out there. There is a wonderful lady who comes in three times a day to help bathe and feed my father. She has no formal training, but she could teach nursing students how to prevent pressure sores. She cares for a number of older people and keeps them engaged and connected. Her assistance and expertise are priceless.

So how does this relate to the geriatrician workforce challenges we are facing in academic medicine?

We should focus on older students. Because their own parents are probably close to needing geriatric care, it’s easier for them to “get it.”

We need a fast-track retraining program in geriatrics for licensed physicians. I appreciate trained geriatricians so much more now than I did 30 years ago, when I opted to specialize in anesthesiology. Retraining could provide a way for experienced physicians to add to their qualifications and give back to society.

We need a residency/fellowship experience that is community-based and patient-centric. We must teach practitioners to help seniors age in place and create networks of community care.

Academic medicine has a wonderful opportunity to develop a commitment outside of our acute-care facilities, leveraging provider training programs and population-based research to create a sustainable pipeline of geriatricians.

This was written by a doctor and published in a doctor-oriented forum. In just the last few hours the comments thread is already getting negative feedback. I want to say something supportive and encouraging but when a level of professional cynicism is apparent toward a colleague, there is no reason to imagine anything said by a layman would carry any weight. 

Perhaps the relentless drone of the GOP primary candidates is getting on my nerves but I'm having a hard time feeling optimistic about the future of health care. Every item in today's list is a bleeding sore in "the world's best medical care" and I  haven't heard a word from any candidate suggesting we address any of them. The last thirty or forty years have resulted in record profits for drug and device companies, a flourishing private insurance industry, somethig like a trillion dollars in student debt (owed, of course, to the Education Industrial Complex) and spreading homelessness and poverty. We are witnessing a train wreck of historic proportions and all I hear is the ghost of Ronald Reagan prating about big government, too much regulation and high taxes. 

I'm thinking about resuming smoking and learning how to binge drink. 

Psychopaths as the rule rather than exception

By BJ Bjornson

It has been bandied about for some time that the banksters who caused the crash of 2008, hoovered the taxpayers dry in bailouts, and continued to lavish themselves with massive bonuses and perks while the rest of the economy struggled are little better than psychopaths. The scary part is that it is no accident.

In a paper recently published in the Journal of Business Ethics entitled "The Corporate Psychopaths: Theory of the Global Financial Crisis", Clive R Boddy identifies these people as psychopaths.

"They are," he says, "simply the 1 per cent of people who have no conscience or empathy." And he argues: "Psychopaths, rising to key senior positions within modern financial corporations, where they are able to influence the moral climate of the whole organisation and yield considerable power, have largely caused the [banking] crisis'.

And Mr Boddy is not alone. In Jon Ronson's widely acclaimed book The Psychopath Test, Professor Robert Hare told the author: "I should have spent some time inside the Stock Exchange as well. Serial killer psychopaths ruin families. Corporate and political and religious psychopaths ruin economies. They ruin societies."

Cut to a pleasantly warm evening in Bahrain. My companion, a senior UK investment banker and I, are discussing the most successful banking types we know and what makes them tick. I argue that they often conform to the characteristics displayed by social psychopaths. To my surprise, my friend agrees.

He then makes an astonishing confession: "At one major investment bank for which I worked, we used psychometric testing to recruit social psychopaths because their characteristics exactly suited them to senior corporate finance roles."

Little wonder the financial world is so screwed up, isn’t it?

The Canada Party

By BJ Bjornson

Because there is no way I could resist posting such a fun video.

"The cannibal capitalism that produced a Goldman Sachs and a Bernie Madoff is subhuman and obscene."

By John Ballard

Doc Searls put together some choice observations of Hal Crowther and furnishes a link to the archive.  If you're feeling dry, go there and drink your fill. 

• “Go get a bath right after you get a job,” snarls Newt Gingrich, an influence-peddler who’s had no legitimate job for 15 years and exists only to give the word “hypocrisy” a human face.
• The cannibal capitalism that produced a Goldman Sachs and a Bernie Madoff is subhuman and obscene. There’s no form of government more inherently offensive than plutocracy—only theocracy comes close. When a citizen comes of age in a plutocracy, he has no moral choice but to slay Pluto or die trying.
• ...two protective myths, transparently false but widely accepted: one, that the feeble, compliant federal government was somehow the enemy of free enterprise; two, the outrageous trickle-down theory, which urged us to choke the rich with riches in the hope that they would disgorge a few crumbs for the peasants.

 

What would an Obama loss mean?

By BJ Bjornson

While it may be difficult to determine just why Obama himself would want to face another four years of the rather thankless task of running a country that rarely seems to appreciate any of his efforts, it isn’t so hard to find reasons why everyone else should like to see him be successful in November. In that vein, The Washington Monthly has a series out on the consequences of a GOP victory, all of which is well worth the read.

The first of the series is a good reminder that, despite conventional wisdom, we should be paying attention to the promises made by GOP candidates during the primaries, since they actually do indicate what kind of agenda the candidate will try to implement once elected.

I suspect that many Americans would be quite skeptical of the idea that elected officials, presidents included, try to keep the promises they made on the campaign trail. The presumption is that politicians are liars who say what voters want to hear to get elected and then behave very differently once in office. The press is especially prone to discount the more extreme positions candidates take in primaries on the expectation that they will “move to the center” in the general election. Certainly everyone can recall specific examples of broken promises, from Barack Obama not closing Gitmo to George W. Bush and “nation building” . . .

Political scientists, however, have been studying this question for some time, and what they’ve found is that out-and-out high-profile broken pledges like George H. W. Bush’s are the exception, not the rule. That’s what two book-length studies from the 1980s found. Michael Krukones in Promises and Performance: Presidential Campaigns as Policy Predictors (1984) established that about 75 percent of the promises made by presidents from Woodrow Wilson through Jimmy Carter were kept. In Presidents and Promises: From Campaign Pledge to Presidential Performance (1985), Jeff Fishel looked at campaigns from John F. Kennedy through Ronald Reagan. What he found was that presidents invariably attempt to carry out their promises; the main reason some pledges are not redeemed is congressional opposition, not presidential flip-flopping. Similarly, Gerald Pomper studied party platforms, and discovered that the promises parties made were consistent with their postelection agendas. More recent and smaller-scale papers have confirmed the main point: presidents’ agendas are clearly telegraphed in their campaigns.

It is a lot easier to get upset at promises broken than those kept, particularly if your support of the candidate was based on some of those promises, which does explain a lot of the disappointment with Obama. Although in Obama’s case, the increase in attention and troops to the Afghan campaign has been treated like a promise broken by a lot of progressives even though it actually is a promise kept. Even there, paying attention to what he was saying as a candidate would have been helpful.

And it is not like anyone should be surprised by what the Republican’s agenda will be once they are elected. Not only have they been trumpeting their priorities for quite some time, they have been carrying them out on smaller scales wherever they control the government at the state level. Bernstein’s piece is about paying attention to what they are saying now, but Charles Pierce made the same point back last November when voters went to the polls to reverse some of the more egregious legislation pushed through by their Republican state governments.

I have become impatient over the past few years with the concept of "buyer's remorse." This notion pops up anywhere a freely elected Republican legislative majority and a freely elected Republican governor get together and put in place policies of the sort they were freely elected to enact. Suddenly, vast numbers of people see Republicans behaving like Republicans and profess themselves shocked — SHOCKED! — to find that there is wingnuttery going on in here. We've seen this with Walker in Wisconsin, Kasich in Ohio, Rick Snyder in Michigan, and Rick Scott in Florida. And, "But they didn't say they were going to do this when they ran!" is a vain and witless excuse. Republicans do what Republicans do. 

Look, folks. Everybody knew who was behind Walker in Wisconsin, and why they were behind them. The same is true of Kasich and Snyder and all the rest of them. Hell, Rick Scott was a convicted felon. Anyone who didn't know any of this either wasn't paying attention, or didn't give enough of a damn for it to matter and voted for these guys anyway. Which, come to think of it, fairly well sums up what happened in the 2010 midterms. The country handed itself over to ignorance and apathy and let those two scamps run amok in the process of self-government. The country doesn't get to wake up, blinking, in 2011 and wonder how all this happened.

It all happened because you let talk-radio drive the narrative in your tiny little minds. It all happened because you let yourself be convinced by grifters and charlatans that an insurance-industry-friendly health-care bill was the first in a series of Nuremberg Rallies. You people went to the market. You came home with the bag of magic beans. You all set the throttle to Full, cut all the brake-lines, and sent your elected governments careering down the slopes of Nutball Mountain. It's a little late now to decide that you don't have the stomach for the trip.

This is a case of not only being warned, but having recent examples to demonstrate how things will go should the warnings not be heeded, and there are longer term consequences to a Republican victory, which Dahlia Lithwick covers in her piece, The Courts:

If a Republican successor of Obama gets to replace both Kennedy and Ginsburg, it’s fair to predict that the Roberts Court may include five or even six of the most conservative jurists since the FDR era. Following the ideological disappointment that was David Souter, Republicans have been spectacularly successful in selecting and confirming justices who consistently vote for conservative outcomes. Indeed, the replacement of moderate Sandra Day O’Connor with Samuel Alito may have produced the most consequential shift at the Court in our lifetimes; in a few short years O’Connor’s pragmatic legal doctrine in areas ranging from abortion to affirmative action to campaign finance reform has been displaced by rulings that would make Edwin Meese’s heart sing.

But it’s not just the Supreme Court that would tilt further right. The high court only hears seventy-some cases each year. The vast majority of disputes are resolved by the federal appellate courts, which are the last stop for almost every federal litigant in the country. And the one legacy of which George W. Bush can be most proud is his fundamental transformation of the lower federal judiciary—a change that happened almost completely undetected by the left. At a Federalist Society meeting in 2008, Bush boasted that he had seated more than a third of the federal judges expected to be serving when he left office, most of them younger and more conservative than their colleagues, all tenured for life and in control of the majority of the federal circuit courts of appeals. The consequences of that change at the appeals court level were as profound as they were unnoticed. As Charlie Savage of the New York Times put it at the time, the Bush judges “have been more likely than their colleagues to favor corporations over regulators and people alleging discrimination, and to favor government over people who claim rights violations. They have also been more likely to throw out cases on technical grounds, like rejecting plaintiffs’ standing to sue.” In short, they have copied and amplified the larger trends at the Roberts Court: a jurisprudence that skews pro-business, pro-life, anti-environment, and toward entangling the church with the state. Under the rhetorical banners of “modesty” and “humility” and “strict construction,” the rightward shift has done more to restore a pre-New Deal legal landscape than any legislative or policy change might have done.

The courts issue is one that more people should be paying attention to. From the Citizens United decision that is starting to get attention thanks to its likely effects on this election season, to the Supreme Court giving a hand to anyone who wants to avoid equal pay litigation, other decisions narrowing of the scope of class-action lawsuits to the benefit of big corporations, to more recently, a judge giving the state GOP in Wisconsin sole access to the court in their challenge to the Dems petition to recall the GOP governor.

A judge in Wisconsin has ruled that Democratic recall organizers cannot challenge a lawsuit brought by the state GOP against election officials — a suit that claims Gov. Scott Walker’s constitutional rights are being violated by the state’s petition review process.

This means that barring a hypothetical appeal, any continuing litigation in this matter will be conducted exclusively between the state GOP and the election board’s attorney, without the Dems themselves being able to participate and present legal arguments.

“I was a little surprised,” said Jeremy Levinson, the attorney for the recall committee, in an interview with TPM. “It’s the first time I can recall — let me rephrase — it’s the first time I’m aware of a recall-related lawsuit where only the official who is being targeted for recall gets to be a party, and the folks who are working to recall that official are shut out of the process.”

The appointed judge was a Republican state Senator for 20 years, and was nominated by Bush for a federal circuit position. Welcome to the future. Not too surprisingly under the circumstances, the GOP subsequently won the case.

Despite these rather real differences between the parties, there remains a quite vocal group on the left stating they’d rather sit things out and allow Obama to go down to defeat since he’s disappointed them on too many issues. Or even worse, those that figure things are going to get worse anyway, so they might as well just get there sooner than later. The latter reminds me of one of the tracks used by climate change denialists, who point out that since they can’t stop climate change from happening, we shouldn’t bother doing anything to mitigate it either, even though mitigating a problem when you have the chance is probably the only way to give yourself enough time to build the movement you need to truly deal with it.

One Reason

By BJ Bjornson

Once again, The Onion wins the intertubz by putting into Obama’s mouth the words Ron has spoken here a few times.

Arguing he'd have to be certifiably insane or some kind of sadistic freak to extend his presidency, Obama asked why anyone with half a brain would willingly open himself up to constant vilification by media strategists, or place himself in a situation that involves so much work for such little reward. He also asked the audience how "messed up and sick" he'd have to be to devote nearly a decade of his life to an unending cycle of political gamesmanship that stifles progress at every turn.

. . .

"I have a pen and some paper right here," Obama said Wednesday morning at a town hall meeting in Ohio. "Let's list the pros and cons of being president. Con: There are people out there who literally want to shoot you dead. Con: We live in a country seriously considering a Newt Gingrich White House. Con: You can help 40 million Americans receive health care, sign legislation that regulates a financial system run amok, give the order to kill Osama bin Laden, help topple Muammar Qaddafi's tyrannical regime without losing the life of one American soldier, end the war in Iraq, repeal Don't Ask, Don't Tell, stave off a second Great Depression, take out more than 30 top al- Qaeda leaders, and somehow everyone still calls you the next Jimmy Carter."

"Can anyone out there name a pro?" continued Obama, gesturing at the silent crowd with his pen. "That's okay. I asked a bunch of people in Pittsburgh the same exact question yesterday, and they couldn't, either."

As with all good satire, there is more than a bit of truth here. It is really hard for me to figure out why anyone would want Obama’s job. It was bad enough four years ago when he knew he’d be inheriting a mess of ridiculous proportions, but after three years of facing not only lock-step obstructionism from the Republicans, but also a withering assault from his own side’s interest groups for not acting swiftly or correctly enough on their issues, and the always fun to watch backstabbing and undermining from the Blue Dog Congressional caucus, I honestly can’t think of any reason why Obama might not want to just tell everyone to take a flying leap and suffer under whoever they think can replace him.

The routine suppressing of drug research

By BJ Bjornson

Today’s scary reading comes from McClatchy:

Drug research, even from clinical trials sponsored by the federal government, routinely is suppressed, harming patients and increasing health care costs, according to new data highlighting an ethical controversy that continues to plague the field of medicine.

. . .

From diabetes drugs to spine surgery products, scandals involving concealed data have mounted. Consider the cases of two heart drugs that were the subject of Milwaukee Journal Sentinel stories:

For two years, Schering-Plough, the maker of the popular cholesterol drug Vytorin, sat on the results of a clinical trial showing the drug provided no benefit in improving artery health. During that time the drug was heavily marketed to consumers in TV ads. The situation came to light in 2008 after a congressional investigation was launched.

In 2003, a clinical trial of Multaq, a drug that treated irregular heartbeat, was stopped because more patients who were getting the drug were dying than those who were getting a placebo. However, the study was not published until five years later.

In 2007, an independent analysis of the diabetes drug Avandia found that the drug increased heart attacks and cardiovascular deaths.

Steve Nissen, the lead author of the analysis, said 35 of the 42 studies he looked at were unpublished and were obtained only because a court case required the drug's maker, GlaxoSmithKline, to turn over the data.

Drug companies may have been the focus of most of the criticism, medical device makers also come in for their share of suppressing data, particularly Medtronic, where a paper written by several surgeons receiving millions in royalties from the company failed to publish a the results of a clinical trial showing problems with a bone-growth stimulating product.

And lest it be said that it is only the companies themselves keeping vital data out of the light, government-funded research isn’t faring much better.

A surprising finding in the BMJ analysis was that serious lapses occurred even in clinical trials funded by the National Institutes of Health.

That research showed that less than half of NIH-funded clinical trials were published in a medical journal within 30 months of the completion of the trial and after 51 months, one-third of trials remained unpublished.

. . .

A second BMJ paper looked at clinical trials of drugs that already had received at least one Food and Drug Administration approval. In such cases a law requires the reporting within one year of the completion of the trial.

Despite the law, only 163 of 738 such trials, or 22 percent, had reported the results within a year, the paper found.

Makes you feel all warm and fuzzy inside, doesn’t it?

Iowa Caucuses

By BJ Bjornson

If the early primaries are mostly about expectations, Mitt Romney has to be feeling pretty good this morning. Sure, his first-place finish is so close as to remain almost provisional, but the real danger going into the caucuses was that his support was soft enough that he’d wind up placing third behind Paul and Santorum, and possibly even worse had Gingrich’s support not already plummeted. (And make no mistake that many of us watching were hoping for such a result, as it would speak to a longer and messier GOP primary.)

Looking forward, Romney is polling well enough that he should have a lock on New Hampshire, which means the next major stumbling block for Romney will come on the 21st in South Carolina. I haven’t paid any real attention to polling in S.C. outside of noting that the last I checked, Gingrich was well ahead. Of the two candidates who also did well in Iowa, Paul is a lunatic who will fade quickly, and Santorum is a lunatic who should play well with the social conservative lunatics that have taken over the Republican party, but lacks funding and nationwide infrastructure to run a real race against Romney. Still, if memory serves, South Carolina was one of those states in 2008 where another candidate with limited funding and infrastructure, Huckabee, still parlayed his evangelical roots to a number of victories in the Bible Belt.

With Rick Perry now pretty much out of the race, there isn’t anyone left who can really run a 50-state campaign against Romney, which, despite however many stumbles his immediate future holds, bodes well for Romney being the eventual nominee. Nate Silver does a good job of summing things up:

However, even if Mr. Santorum catches fire, or even if Jon M. Huntsman Jr. surges in the polls, or even if (perhaps less plausibly) Newt Gingrich somehow resurrects himself yet again, Mr. Romney will have a lot of second and third chances. Mr. Romney could lose South Carolina but win Florida. He could lose South Carolina and Florida but rebound in the caucus states of February, or on Super Tuesday. He could be engaged in a more-or-less even delegate battle with someone like Mr. Santorum for a long while — but emerge with the most delegates at the end.

Some of these scenarios are not great for Mr. Romney. There is certainly the chance that he wins the nomination without really capturing Republican voters’ hearts and minds, and that might Republican impact turnout at the margin in November.

. . .

The bottom line is that Mr. Romney’s chances of becoming president are a little higher than they were 24 hours ago, quite a bit higher than they were 24 days ago, and much higher than they were 24 months ago, when he was one of among dozens of potential aspirants to the nomination. If Mr. Romney achieves his goal, he will have some more aesthetically-pleasing victories along the way.

I suspect short of some very unlikely scenarios, the establishment and media (but I repeat myself) will crown Romney the nominee as soon as they plausibly can so they can move onto the real battle between him and Obama.

Oh well, sometimes when you root for injuries, you just have to resign yourself to the fact there just won’t be that many.

Daily Must Read

Commentary By Ron Beasley

If you are not reading Charles P. Pierce everyday you should be.  He is a great writer who is factual and snarky.  He makes you laugh even when the news is bad.  He is the writer I wish I was.  Today he points out how ridiculous it is that conservatives are upset that the Republican candidates are a pretty sorry lot.

Precisely how many times are we going to be treated to public expressions of mock horror from Important Conservatives that 40 years of allying themselves with nativist hooligans, anti-intellectual crackpots, Christomaniacs, and the sad detritus of American apartheid finally has produced a field of presidential candidates that these same Important Conservatives find less than adequate? Once again, the whole exercise requires both the writer and the reader to ignore the obvious consequences of four decades of political history and conclude that the Republican party has lost its mind only recently. And it requires both the writer and reader to convince themselves that out there, somewhere, is a superior candidate to the ones presently available, and to ignore the obvious conclusion that titans like Chris Christie, Mitch Daniels, Jeb Bush, and Paul Ryan chose not to run because they suspected they might get beaten like gongs, if not by President Obama, then by the wholly unacceptable Willard Romney.

Yes indeed, the Republican party we see today has it's origin with Lee Attwater forty years ago.  The "Southern Strategy" - capture the south from the Democratic Party.  This was as Charlie says was an attempt to capture the" nativist hooligans, anti-intellectual crackpots, Christomaniacs, and the sad detritus of American apartheid". It worked for years - pandering was enough, but the lunatics have taken over the asylum.  

Doug Matacoins is upset that ultra conservative Catholic Rick Santorum wants to outlaw birth control.  The  lunatics have taken over the asylum Doug and you let them in. 

HCR -- ACA Implementation Timeline -- Bookmark This

By John Ballard

The Kaiser people have produced an interactive website to track the eight-year unfolding of the Affordable Care Act.  

 

Topics are individually searchable and the site is interactive.

For example, if you want to know about the much-discussed individual mandate check the "Insurance" box in the left column. Then find 2014 and click on the +  sign for a drop-down menu.

The first menu item is "Individual Requirement to Have Insurance."

Again, click on the + sign
The information box says

Requires U.S. citizens and legal residents to have qualifying health coverage (there is a phased-in tax penalty for those without coverage, with certain exemptions).

Implementation: January 1, 2014

Learn more: How will the requirement that people be insured or pay a penalty work under the health reform law? This simple infographic explains how “the individual mandate” works.

The infographic will give you an idea about the complexity of the healthcare system in America. 

Whenever you hear the term "Obamacare" which has become something of a nasty, sarcastic alternative tag for this legislation, ask yourself if all the work that went into the design and planning of this body of law really needs to be "repealed."

That is the word being used repeatedly by the GOP candidates and I am certain they know (a) it ain't gonna happen and (b) if more Americans knew what was in the legislation they would not want it to happen. 

Well, I take part of that back. There are a couple of candidates so ignorant that they really don't know it will not be repealed and very likely will never know what's in it.  I never thought ignorance and stupidity could rise to the level we have seen over the past few months, but I have a feeling that the madness has only just started. 

If the Obama campaign doesn't capitalize on this level of ignorance there will be no excuses and he will deserve not to be re-elected. Given what is here and how many people don't know about it there will be no need for any "October surprise." As soon as the campaign gets going defending ACA should be like shooting fish in a barrel.