From the Montgomery Advertiser:

MONTGOMERY — Gov. Robert Bentley said Thursday after a speech at a legal conference that his administration is considering expansion of Alabama’s Medicaid program, but has not made a final decision.

Bentley said he was concerned about the health care access for the state’s working poor and rural health care infrastructure.

However, Bentley said a stumbling block is figuring out a way to fund the state’s share of costs.

Thirty states have expanded Medicaid under President Obama’s health care law.

The governor has previously said he might support a state-designed program with work and premium requirements on recipients.

Remind the governor that the state needs this and that states that have expanded have seen increased tax revenue and lower costs of care for their citizens.

From Kaiser Family Foundation

If all states accepted the expansion:

  • The number of nonelderly people enrolled in Medicaid would increase by nearly 7 million, or 40 percent.
  • 4.3 million fewer people would be uninsured.
  • There would be $472 billion more federal Medicaid spending from 2015 to 2024.
  • States would spend $38 billion more on Medicaid from 2015 to 2024.
  • Savings on reduced uncompensated care would offset between 13 and 25 percent of that additional state spending.
  • States would be able to realize other types of budgetary savings if they expanded Medicaid that are not included in this report.

Remind the governor that a major cause of bankruptcy is unpaid medical bills from catastrophic illnesses and Medicaid protects people from this and in general people with Medicaid get better quicker.

From Urban Institute

Why insurance is important for folks:

Uninsured people receive less medical care and less timely care, they have worse health outcomes, and lack of insurance is a fiscal burden for them and their families. Moreover, the benefits of expanding coverage outweigh the costs for added services. Safety-net care from hospitals and clinics improves access to care but does not fully substitute for health insurance.

And let the governor know that despite the beliefs of our delegation, “repeal and replace” is not an option in Congress so let’s work with what we can get:

From The Hill

Repealing the Medicaid expansion is a dicey proposition for endangered Senate incumbents running in four states: Illinois, Ohio, New Hampshire and Pennsylvania, all of which broadened Medicaid.

Another Senate Republican, speaking on condition of anonymity, expressed concern that states that expanded Medicaid would be penalized by billions of dollars if Congress repealed the federal assistance.

“Repealing the Medicaid expansion is not going to be in there because it’s too problematic for many Republicans,” said the lawmaker, adding, “I don’t want to stick the state with the bill.”

Here is the governor’s contact information. Let him know what you think.

What should be huge medical news is that the mortality rate (the rate at which people die) for white men and women aged 45 to 54 with less than a college education is rising in this country. This despite all the money that is spent on health care. This just does not happen. Why is this? Per the Washington Post:

“Drugs and alcohol, and suicide . . . are clearly the proximate cause,” said Angus Deaton, the 2015 Nobel laureate in economics, who co-authored the paper with his wife, Anne Case. Both are economics professors at Princeton University.


And we are talking about a lot of excess deaths

Based on the findings, Deaton and Case calculated that 488,500 Americans had died during that period who would have been alive if the trend hadn’t reversed.

There is a lot of speculation about the exact why and more studies are certain to follow, It is clear that the economic recovery has left these people behind and it is also clear that the safety net, including mental health but also including meaningful retraining, has not been effective for this group of people. For now, as a physician I need to do a better job of screening for pathological substance use and mental illness, As citizens we all need to advocate for more, not less, support services for this at risk population. As people, we can all say out neighbor “Is there anything I can do to help?”

How can Dr Carson be leading in a national poll for president and get a pass on a some, well, scientifically suspect beliefs such as “his statement in the wake of the Oregon mass shooting that it would be advisable to attack an armed gunman during a mass shooting ‘because he can’t get us all‘?” Or. how can folks want a president who is doing infomercials on neutraceuticals which misrepresent scientific fact and when called on it, deny having been paid for what was almost certainly a paid gig?

The New York Times gives a plausible answer to this question today. Ishani Ganguli, a Boston internist with an interest in health policy, points out that, pretty much, physicians get a bye:

  • He points out that we are trained to speak authoritatively regardless of the certainty of the situation or the strength of the evidence. In other words, as I tell my residents, “patients and attendings smell fear.”
  • He points out that surgeons are trained to believe that their skill is what stands between the patient and death and the loss of that faith leads to a crisis, one that a successful surgeon may never experience. He or she may not be good (and there is now a scorecard to look at) but will never admit defeat.
  • Doctors should never be politically correct, or so they are portrayed in the media (see House, MD),
  • There is a long line of physicians who are given a pass (see Dr Oz for the latest example)

Dr Ganguli points out that we as a society feel the need to ascribe trust to the MD. Our Hippocratic sales pitch has been an effective marketing strategy. He goes on to point out that self reflection and knowing our limits are keys to maintaining this trust. I am afraid that these are qualities Dr Carson does not have.

139263_600Ben Carson on setting up health savings accounts in a post Obamacare world:

“You also give people flexibility to transfer money within a family. So if you were $500 short, your wife could give it to you, your daughter could give it to you, your uncle, your cousin.”

Me in conversation with a fellow who is homeless and suffers from a terminal illness last week:

“Can you give me a ride? I sleep in a cot in the shelter down the way. I worked all my life until I got sick. Just got discharged a week ago from the hospital. Can walk about a half a block before I have to rest. I spend my morning walking to the this place for food.”

Me: “How long does it take you?”

“Oh, all morning. It’s about 3/4 of a mile. I spend the afternoon walking back. The give me a lot of medicines but when I run out I end up back in the hospital”

From a blog on population health

…..success (in lowering healthcare costs and increasing quality of healthcare/better outcomes for patients) …will require the ability to embrace the messiness of disease and the complexity of patients, rather than providing idealized solutions that impress in the boardroom but flop in the examination.

It is refreshing not to have a wonkish campaign for the Republican nomination. Both 8 years ago and 4 years ago terms like “bending the cost curve” and “medical loss ratio” were being used by the actual candidates. Voters don’t want to hear that. They want common sense solutions for common sense problems. For healthcare, the answers are simple—after all, we’ve all been to the doctor, right? Make the sick folks make choices. Get ’em out and working. Since Dr Carson is, well, a doctor, his common sense answers are just the prescription for our sore ears.

As found here, he feels that Health Savings Accounts for almost all are just what the doctor ordered:

ObamaCare, he opines, is way too restricting. Why should people need to have the details of what they purchase?

A major problem is that many people in our entitlement society see nothing wrong with forcing others to provide for their desires. In a free and open society, anyone should be able to purchase anything they want that is legal.

Given enough freedom, the invisible hand will sort things out:

Most people will want to get the biggest bang for the buck and will independently seek out both value and quality. That, in turn, will bring all aspects of medicine into the free-market economic model, thus automatically having an ameliorating effect on pricing transparency and quality of outcomes.

In addition, the miracle of compound interest will overcome the human predisposition to become sicker as we get older:

If accounts are established at the time of birth, they will be even more potent because the vast majority of people will not experience catastrophic or even major medical events until well into adulthood. By that time, a great deal of money will have accumulated.

Lastly, Americans are generous to a fault and will contribute to a fund if it goes to those who are deserving:

The 5 percent of patients with complex pre-existing or acquired maladies would need to be taken care of through a different system, similar to Medicare and Medicaid, but informed by the many mistakes in those programs from which we can learn. Even this kind of system should have elements of personal responsibility woven into it.

Problem is, facts really get in the way of an attractive market-based narrative:

  1. Healthcare in this country costs about $8,000 annually for each man, woman, and child, of which the government currently pays around $5,000.- President Carson would put $2,000 into everyone’s account. Already he’s saved us money!
  2. Five percent of the population accounts for almost half (49 percent) of total health care expenses with most of those people being on Medicare or Medicaid.- Um, does that mean we bonus everyone $2,000 and then have to pay the same amount for folks on Medicare anyway? Or does their account magically grow? 
  3. The lower 50 percent of spenders accounted for 3 percent of the total national health care dollar.- Uh, oh, here’s a problem. We have taken this money out of health care and moved it into a savings account for healthy people.
  4. High spending persists over multiple years for many patients, while others return to more normal spending levels after an expensive episode. There is also evidence that high spending occurs near the end of life for many patients, particularly within the Medicare population- Well, this is a problem…what happens when the savings account runs out? I guess they are walking to the homeless food site.

Interestingly, Dr Carson performed operations that cost the patient’s insurance $3,000,000 on a routine basis. He never published his results, but the operation he became famous for (separation of twins joined at the head) apparently has a mortality of 50%, and an unknown but high rate of severe disability. It is clear that informed consent remains a real problem regarding outcomes without surgery. Since these operations occur in the first year of life, the twins could kick in the first $4,000 from their HSA. Wonder if having to collect $2,996,000 from the health savings accounts of 1498 of the parent’s closest friends and family would make a difference?

Me, I’m now into the Donald’s plan:

Trump said that the Affordable Care Act has “gotta go” and that he would repeal the law and replace it with “something terrific.”


Me (while in the military): Well, why can’t we do it this way. This person is malingering and really needs to be “not in the Marines.”

My superior: You really don’t want to. This person might be a screw-up but he is well connected and you really don’t want to start a “congressional.”

In Hawaii, where I was stationed, we lived in fear of “congressionals.” Some enlisted person or another would get what he or she perceived as bad care and before you new it, a letter from a congressperson’s staffer would appear on the commanding officer’s desk.

Dear Captain (blank),

This is to inform you that one of our constituents feels that the care they received  was substandard. Please provide in writing the circumstances surrounding this incident. 


Congressman Foghorn Leghorn

This letter would initiate a chain of events that resulted in all productive activity stopping until all of the minute details could be compiled into a mountain of paperwork and sent “up the chain.” The reality was that the Congresspeople probably could care less about what actually happened but, being the representative of the people, wanted to respond (or be seen as responding) to their constituent. The actual effect was to keep us from doing what we were being paid to do, provide quality care to the troops, and instead focus on the distraction.

This past week our Congressman, Bradley Byrne, responded to what he perceived his constituents wanted. He voted aye on a blank check for congress to “investigate” Planned Parenthood’s role in, I don’t know, having a disturbing lunch conversation regarding embryonic tissue donation. (If you want an in-depth discussion on the ethics of the use of cells in scientific discovery, a good source is this book.)

The investigation, though, seems not to be investigating the use of embryonic tissue in medical advances (think rubella and varicella vaccine) but, very specifically:

Requires the Panel to investigate and report on:

  • medical procedures and business practices used by entities involved in fetal tissue procurement;
  • any other relevant matters with respect to such procurement;
  • federal funding and support for abortion providers;
  • the practices of providers of second and third trimester abortions, including partial birth abortion and procedures that may lead to a child born alive as a result of an attempted abortion;
  • medical procedures for the care of a child born alive as a result of an attempted abortion; and
  • any changes in law or regulation necessary resulting from such findings

Congressman Byrne, please don’t let them turn this into an expensive distraction. Let’s investigate how to make it REALLY difficult for these entities to procure fetal tissue by making pregnancy termination rare. I would ask that Congress use the  “any other relevant matter” clause to investigate the real causes of our abortion crisis and these should include:

  1. In states that have not expanded Medicaid, working parents are only eligible for Medicaid if their incomes are below 61 percent of the poverty line (about $11,900 for a family of three), and jobless parents must have incomes below 37 percent of the poverty line (about $7,200 a year for a family of three). In most states, Medicaid coverage is not available at all to adults without children. This large group of people does not have easy access to long-term effective contraception and thus is more likely to have an unwanted pregnancy and seek out pregnancy termination. How are these states responding to the challenge?
  2. Health coverage during the period before pregnancy allows women to receive preventive care like regular doctor visits, birth control, information about making healthy food choices, tobacco cessation programs, and substance abuse services that decreases their own health risks and makes it more likely that their babies will be born healthy if and when they become pregnant. For example, research shows that prenatal care for high-risk pregnant women reduces the incidence of costly premature births. In states that have not expanded coverage. these people only seek care after they become aware of their pregnancy and make a conscious decision to go to the doctor’s office. They are more likely to have a fetus with a problem and seek out termination. What are we doing to provide access to women prior to conception in the states that have not accepted expansion?
  3. By accepting the Medicaid expansion and eliminating gaps in coverage, the state administrative costs are reduced because the states  no longer have to process enrollment and disenrollment for women who move on and off Medicaid coverage based on pregnancy, thus reducing the size of government and saving the state needed tax revenue that could be returned to the taxpayers. In those states not accepting the expansion, how are they justifying this needless expansion of bureaucracy?

I expect my response soon.

Signed, your constituent and a taxpayer.


When last we left the village (about 2 weeks ago) whose entire existence was to support pulling babies form the stream, a search party had gone upstream to find out where the babies were coming from. Meanwhile there were still babies coming down the stream. As you may remember, a very sophisticated infrastructure had arisen to pull the babies from the stream. The folks who took the lead, the “baby savers,” took their job very seriously and were valued. They often had to jump in and save babies who were coming down or might have to manipulate the equipment to pluck one from the waterfall. As befits their importance, they were paid very well and had an honored place in the village.

The baby savers executive committee, already threatened by the fear that the search party might find where the babies are coming from and put a stop to it, began looking somewhat critically at the entire operation:

Baby saver president: As you know, we have been looking into the “babies in the stream” issue. We have a lot of folks who care a whole lot about babies and have been giving  there time to make sure the babies are pulled safely from the water. However, it seems there is room for improvement.

Village baby saver: What do you mean improvement, we work our butts off.

Village baby saver 2: Yeah, we are up all night. Often I have to jump in. The water is cold.

Baby saver president: Well, we have started to keep track of your work and, to be honest, we are not doing some of the things we should. As you know, we pay you by the baby.

Village baby saver 3: Your point?

Baby saver president: Not to name names, but I think we should have thought through this more carefully. I’m not going to name names, but one of you pulls out a lot of babies. Many of these babies are blue when they come out and the baby resuscitators are complaining. They say you (not to name names) are too rough and push others out of the way so that you can get the most babies.

Village baby saver 2: They are just jealous.

Baby saver president: And one of you, again I’m not naming names, is just too old to do this. Your eyesight is poor and you don’t swim well. The resuscitators have to jump in and grab your babies but then you take credit.

Village baby saver 3: They need to step back and let me do my job.

Baby saver president: I suspect the search party will be successful and there will be many fewer babies going forward. So we are going to start posting how well you do on the wall over there and it may well be that some of you won’t be able to be baby savers any more. From now on, everyone will know how many babies you catch, what percent are blue, and how many went over the waterfall that you should have saved.

Village baby savers (talking at once): wait, that isn’t fair. How is it my problem if they come down too fast? What if more than 2 people are on a shift? I have a wife and kids to feed. Those resuscitators can kiss my…

If you want to see how hospitals do in regards to preventable mortality and certain procedures and use that to pick your hospital, the government’s hospital compare website is for you (go to this site). If you want to see if your hospital or surgeon has an unusual number of complications or just doesn’t do a lot of the procedures that you need, Propublica has a tool that compares individual surgeons (go to this site). If you want to float along and let a random person pull you out of the water and hope they do a good job, enjoy the ride and I hope you avoid the waterfall.

I am heading to Denver to help my friend John Meigs run for President-Elect of the American Academy of Family Physicians. John is an impressive gentleman and has been active in  trying to bring healthcare to all Alabamians. As he so eloquently states:

The premise of family medicine is centered in the value that an ongoing continuous relationship with a trusted family physician brings to an individual and his or her community.  The promise of family medicine is patient centered care that recognizes the value of the individual as well as the benefits to the larger community of true primary care with effective preventive care and chronic disease management.  This makes us the specialty with the potential to reach the underserved and hopefully make a difference in overcoming the barriers and social determinants of health that affect way too many people in a country as prosperous as ours.  The payoff is the triple aim we talk about of better care of higher quality leading to better health.

He will be an outstanding leader for our organization and will help to further our efforts to bring high end primary care to the American public..

John and the Academy by the numbers

120,900 – the number of physicians and students represented by our academy

4891 – the number of people in the town of Brent, Alabama, where John is from and still lives.

2778  – the number of people in Centreville, Alabama, where John practices.

160 – the number of days John is going to have to give up to the cause if he wins

33 – the number of years John has been in practice

26 – the number of years John has been involved with organized medicine

25 – the number of beds at Bibb County Hospital, where John practices

3 – the number of candidates for president-elect

1 – Last quote

At the heart of primary care is the idea that patients should have an ongoing relationship with a family physician they know and trust. I have that kind of relationship with my patients because I’ve lived here most of my life, and I’ve practiced medicine here for more than 30 years.

If you are a delegate, please consider voting for John. Thank you for your support!

'Let's make a quick stop in Vegas and blame it on an unruly passenger.'

Last night we were at a dinner party where I met an honest to goodness professional poker player. I have to admit that I have never met someone who makes money off poker. Living close to Biloxi (home of several casinos) and knowing a lot of smart people I do know folks who count cards in blackjack. These people tend to be regular folks who can keep a running dialogue in their heads that goes something like +1, +1, -1, -1, +1, hit at 18. Folks who like to go to the casinos for entertainment and can count cards tend not to because it take all of the fun out of it. Folks who try to make a living by counting cards get found out and put on a “No Fly” list for gamblers mostly because the house resents them.

This professional gambler didn’t wear fancy clothes or a lot of jewelry. Turns out she could count cards and win at blackjack, but prefers poker because poker is a game of skill and the house tales a cut then lets players play (to coin a phrase). She is even better at online poker which is where my interest was piqued.

Me: So, I would think that on-line poker would be dominated by computers masquerading as real people

Poker-lady: Not so. Computers are actually not very good at poker.

Me: Really. But they are really good at chess

Poker-lady: Chess is a game where all of the elements are known. When a computer loses at chess it can go back and analyze every move, learning from its mistake and not making the same one again. In poker, there is too much uncertainty. The computer doesn’t know the opponents hole card or betting strategy. Computers don’t do well with uncertainty.

Turns out there is one bot (Cepheas) that is now able to hold its own in a type of poker (head-up limit Texas hold-em). This computer will play a single person (head up) and win money over time if the bet size is prescribed (limit). The computer is the work of AI investigators at the University of Alberta who, aside from trying to build their school’s endowment, are interested in solving the “imperfect information” game. Chess is an example of a perfect information game where all players have all information. In poker, everyone has limited information regarding their situation as well as their opponents’ situation. You know what your hole cards are but not your opponents’.

Doctoring, it turns out, is a game of imperfect information. I know what I have prescribed (medications, exercise, less calories) but have to ferret out what my opponent (patient) is holding (But doctor, when I said I only drink water, I meant to say a liter of soda pop. Does that make my sugars higher?). For years, programmers have tried to write code to do what I do and have been unsuccessful. The folks in Alberta are now working with diabetologists to create a program to help with diabetes:

“It turns out that one of the things a doctor does so well is come up with robust [recommendations] … And that’s what our poker programs have to do, they have to be robust to ‘what are the cards my opponent has, and how does my opponent play?’ ”

So, one day I might be able to use the wily computer to help me with my patient who “just can’t get controlled.” For most of my patients now, the flop is hypertension, diabetes, and hyperlipidemia, Until I get a bot, I’m assuming they have non-compliance and a lack of physical activity as their hole card. Does that make me a cardsharp?


Me: This patient was admitted 10 times in the last year. She needs a good doctor to help her use the system better

Resident: Dr Perkins, she goes to the emergency room because she is an addict. And that is when she is taking her psych meds and not hearing the voices. She’ll only take the pain meds and won’t take any medicine for her diabetes or her blood pressure because they are (air quotes) poisoned (air quotes) 

Me: Don’t you want a challenge?

Resident: Her psychiatrist won’t tell us what medicine she is on or even whether or not he is actually seeing her. Claims it violates the (air quotes) doctor-patient  (air quotes) relationship. And don’t get me started about her drug problem. She has been kicked out of every treatment facility within 50 miles and there is ONLY ONE of them that take Medicaid, anyway. 

Me: Don’t you want a challenge?

Resident: Dr Perkins, don’t do this to me. Let me just refill the diabetes medicine that she won’t take…

Medicine in general has not historically functioned effectively outside of the here and now, meaning we try to fix broken people.  There is a parable that is often used to illustrate the problem with this approach, the parable of the babies in the river. In the story a village mobilizes to deal with a crisis (babies are found floating in a river) and the town folk eventually take on saving babies as their purpose. Finally, the story goes, someone suggests going upstream to determine where the babies as being put into the water. Delivering care to those suffering from complex illness in an academic health centers as I do is much like living in that village. We find ourselves pulling people out of the water meanwhile wishing someone could go upstream and fix the problem. Academic medicine has put together a list of things called the Milestones that our doctors should be willing and able to do. One of these suggests that family physicians should be willing to take that walk upstream and stop the babies from being put into the water in the first place.

The most complex patients do not simply need blood pressure and diabetes medications. Those who are “really sick” typically have multiple poorly controlled chronic illnesses, multiple physicians, and expensive care-seeking behaviors, and no primary care because they do not see a reason to add “one more doctor” into the mix. Also these are people who have problems with housing as either they tend to be impoverished from their illness or they suffer from illness as a consequence of their poverty. They lack access to healthy foods because they tend to live in food deserts associated with poor neighborhoods but also tend to require specialized diets that cost more. They also are more likely to have sought and receive disability and so must live on a fixed income. In addition these patients may have suffered from access to an over exuberant healthcare system and suffer the after effects of having had multiple surgeries and having been on multiple medications with serious side effects,

Atul Gawande wrote of a physician who focused on caring for these complex patients (information and link found here). Caring for these complex patients requires practice based resources such as timely access to clinical services and coordination of services, knowledge of community resources such as housing and healthy food, and a clinical quarterback. The payment structure, although changing, has not changed sufficiently to reward practices that “look upstream.” In addition, medical students and residents come from a model where “the here and now” is rewarded both financially and professionally so they are not looking to move “upstream.” For us to get healthier, our doctors need to be able to focus on the stream AND look upstream as well.

In our training site, we are working on create an nurturing and supportive environment that will allow us to care for these patients. Our hope is that we will allow our complex patients to receive better, more effective care.  Our hope is also that it will provide a lab for our students and residents to see that by partnering with the community, providing “non-medical” things such as housing and appropriate dietary information, and improving access to resources they can care for these patients in addition to providing care for the rest of the community. We will start building this “Chronic Disease Medical Home” annex to our patient centered medical home. I will use this space on occasion to  discuss our progress. Wish us luck!

peter-steiner-i-m-sorry-sir-but-dostoyevsky-is-not-considered-summer-reading-i-ll-h-new-yorker-cartoonTime once again for the summer hiatus, where I spend some quality time with my family, work on other projects, and in general try to stay out of trouble and on the beach as much as possible. For those of you who are looking for a way to become more informed on health policy from a primary care perspective, I have put together several suggested areas of focus.

  1. Population health: The buzzword for the next year is population health. As those of you who read my stuff know, traditional medical care is necessary but not sufficient. America’s “best health care in the world” system will continue to be expensive (#1) and not very effective (#37) until we acknowledge that a whole lot more than doctoring goes into health. For a primer, RAND (link here) has published a synopsis on what works and what doesn’t in this arena. This paper is a good start. Once you get your feet wet, my friend and fellow blogger Josh Freeman has published his book Health, Medicine and Justice: Designing a Fair and Equitable Healthcare System (available on Amazon) which, though focused on our broken system, has a lot of insight about how an emphasis on population health could take us in a better direction.
  2. Palliative care: Death comes to us all. As I watched the movie “The Judge” all I could think about while watching the Robert Duvall character was how movie Frank Burns was old now,which meant I was old, too. In the movie, Robert Duvall’s character has colon cancer (“Stage IV, the worst”) and is suffering from “chemo brain.” His chemo is administered by his GP in his lake house and, aside from hitting the dude on the bicycle and not remembering, it is a pretty idyllic cancer life. He apparently stops chemo and goes on to live for another year, dying  while fishing with his son after they have dealt with old baggage. While health care delivery wasn’t an integral part of the movie, patient choice and shared decision making was. We as Americans say we want that kind of life and death. We seldom get it. Atul Gawande lost his father several years back and has written an exceptional book entitled Being Mortal. It is an excellent read and provides insight into the mismanaged way we deal with chronic illness and terminal care as the inevitable happens.
  3. Obamacare: The Affordable Care act is 5 years old. When all is said and done, this act has begun the process of retooling our care delivery system. For the latest update on what is or is not happening, RAND has provided a summary of where we are after 5 years to get you up to speed (link here). You say you need to walk before you can run? Though I haven’t read is, Ezekiel Emmanuel is one of the architects of the law and has a book out detailing what the law was supposed to do and is doing (link here).  Emmanuel is an ethicist and a very good writer, and I suspect his book will offer some keen insights into why the law has been shaped in this way. From the observer perspective, Steve Brill’s book offers an exceptional synopsis of where we have been and where we are going. If the Supreme Court rules rules in favor of King (in King v Burwell) and dismantles the law, you can read what the conservative response may be for under $4 here. Hurry, though, if the law is struck down prices might go up.

Y’all have a safe and fun summer.





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