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On Thursday, the National Pharmaceutical Council (NPC) and Health Affairs launched a new initiative to address health spending called Going Below the Surface. It's is a "research-first endeavor dedicated to unearthing and examining the drivers of health care spending in the United States, and convening a multiple-stakeholder discussion to better understand what we receive for these investments."  The U.S. spends 18% of GDP on health care which is far more than any other country. And, despite all that money, we have worse outcomes.

David Cutler from Havard University shared a few shocking comparisons. The one that has stuck with me is Duke University Hospital has 900 hospital beds and 1,300 billing clerks. Do you think maybe we could save some money by streamlining how we pay for care?

Amitabh Chandra from Havard University showed this cost curve to illustrate how the first health care dollars spent extend life significantly, but you quickly reach a point where we're spending half a million dollars to extend a person's life by a matter of days. This leads to the tough questions. Who decides where the time isn't worth the expense? Is there one answer for everyone in the country or could individuals choose the coverage they want? 


There are strong incentives in our system to produce low-value innovations. To date, we have not been able to say "no" to low-value care. There is no public support for rationing care, so the government can't put the breaks on, at least not at the federal level. Every other country has figured out that their government is responsible for controlling costs, but there was widespread agreement that we can't look to our government to solve this problem given the current state of affairs. 

Patients rarely have the information they need about cost, outcomes and value to make informed decisions and who among us makes great decisions when we are seriously ill? Even if we had the information hope is engrained in Americans. We believe we or our loved ones will be the excpetional responder to a treatment. To think otherwise is to give up. 

By a show of hands, people seemed split between looking to health care providers and employers to really make some progress. At the moment, my vote goes to the employers. I think Amazon-Buffet-JPMorgan Chase could really do some creative things by joining forces. (Note to self: update resume.) Mollyann Brodie from the Kaiser Family Foundation stated their research shows that people trust their employers. 

I'm particularly interested in how people can be brought together to make value-laden decisions. Craig Mitton touched on this in his presentation and mentioned a deliberative polling practice. I plan to look into Daniel Yankelovich's work on this. I'll share the group decision making process I developed to allocate health care resources soon.

Corinna Sorenson talked about her work evaluating the effectiveness of the Choosing Wisely Campaign. Less than half of the recommendations reduced low-value care and those reductions had limited impact in the 3-5% range. I've been following this initiative for years and thought it had a ton of potential, so the results are discouraging. I heard yesterday that Consumer Reports is pulling out of the initiative and that the National Alliance of Healthcare Purchaser Coalitions is going to step in to fill the void. 

Leslie Greenwald pointed out that our unsustainable spending has been sustained for many years. The healthcare sector employs a lot of people--12% of the population. I heard that at one point Massachussetts wanted to try to curb health care spending and then realized that it would displace so many workers if they were successful that they decided to leave it alone. From an economic standpoint, I think it would be ideal to retrain those billing clerks at Duke to do something that has a greater social value. The one point during this full day of presentations about health care that the audience erupted into spontaneous applause was when it was suggested that we'd be better off taking money out of health care and investing upstream in the social determinants of health. 

This was the kick-off to a two-year initiative so there are understandably more questions than answers at this point. You may have heard that health care is complicated, but that just means we need to allocate more resources to finding solutions. I look forward to seeing what we learn. You can follow along on the Going Below the Surface website and a Health Affairs blog that's dedicated to health spending. 

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Our life expectancy in the U.S. decreased for the second year in a row in 2016 to 78.6 years. The drop looks small at first blush -0.1 years, but it's alarming. Life expectancy in the United States is lower than in most other OECD countries and the gap is getting wider--we're dying earlier in the U.S. while people in other countries are living longer. I could not do as good a job of explaining why as Bill Gardner did in this post, so I recommend you read his explanation. 

How are people dying? These are the leading causes of death according to the CDC.
  1. Heart Disease
  2. Cancer
  3. Accidents
  4. Chronic lower respiratory disease
  5. Stroke
  6. Alzheimer's
  7. Diabetes
  8. Flu and pneumonia
  9. Kidney disease
  10. Suicide
The rate of death decreased for seven of these 10, but increased for accidents, Alzheimer's and suicide. We also know drug overdose deaths rose an appalling 21% from 2015 to 2016


It bears mentioning that it's not too late to get a flu shot. The deaths from flu are largely preventable if we could get enough people vaccinated. If you're not inclined to get a flu shot for your own benefit, do it for the people around you


Please excuse the public service announcement. Now, back to our regularly scheduled programming.

Where the death rate declined for infants and older American's, it increased for people age 15 to 64 and increased for men more than women.  (Life expectancy for women was the same this year as it was last, 81.1 years. However, for men it declined from 76.3 to 76.1.)

The rich have always lived longer than the poor, but here the gap is widening too. The top 1% of male wage earners now live 15 years longer than men in the bottom 1%. (For women, the gap is 10 years.) This shocking chart ran in an article on Vox I recommend reading. 



They're evidently doing something right in California, but the rest of this news is bleak. Surely, we can do better.
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I'm reposting this with permission from Maggie McGary. She shares an interesting perspective on mental health care in this post. You can learn more about Maggie on her blog Mizz Information. I also recommend taking a look at 10+ Photos that Prove Depression Has No Face. 




MENTAL HEALTH STIGMA WHEN YOU’RE NOT A CELEBRITY OR A TEEN
08.25.2017 by  // 1 COMMENT

Mental health has had a banner few weeks in the news and across the internet–at least when the news centers around celebrities or teens. Sinead O’Connor and Justin Bieber made headlines about their battles with depression and mental illness and Diply applauded a list of celebrities who have shared their struggles with mental illness. Two teens were lauded for documentaries about mental illness: one praised for his film raising awareness about mental illness and another whose documentary about suicide won the top prize at a film festival. Headlines like “Young People On ‘Brink Of The Worst Mental Health Crisis In Decades,’” and “Teen suicides now outnumber homicides,” and “Suicide Rate for Teen Girls Hits 40-Year High” are just a few of the too-many-to-list recent news items showcasing how teens are battling depression that make it feel–at least to me–that somehow the world is getting the message that teens are the only ones impacted by mental health issues…well, teens and celebrities.
All this buzz about mental health issues is great, but to me it just highlights a disparity I’ve already written about: the what-feels-like-a-growing-chasm between mental health stigma among celebrities and teens and then among GenX and older generations. While teens and millennials are doing a great job of being open about mental illness in an effort to stop the stigma that surrounds the subject, those of us who grew up being told that mental illness is a shameful secret that you better never tell anyone about or you’ll be labeled crazy, ostracized and probably lose your job…for us, it’s not that simple.


If you’re a celebrity and confess to battling depression or mental illness, you’re hailed as a hero. If you’re a teen, ditto. However, if you’re neither a celebrity, a teen who is either financially supported by parents or a twenty-something who has turned his/her mental health advocacy into a career and are, instead, just a regular non-millennial, non-celebrity with a day job and bills to pay, being open about mental illness isn’t as glamorous or non-risky.
This New York Times article “Deciding Whether to Disclose Mental Disorders to the Boss” states the unfortunate reality facing the 43.7 million adults who suffer from a mental, behavioral or emotional disorder and worry that letting bosses or coworkers know about their illness could cost them their job: “[T]here is reason to worry.”
The article goes on to detail that “…while celebrities and others who have publicized their mental health problems have to some extent reduced the stigma, that is not true in the place people spend most of their waking hours — on the job.” “We’re seeing changes in the broader culture, but we’re not seeing it in the workplace.” A psychologist who has spent years studied the issue of the risk/benefit of disclosing mental illness in the workplace suggests that people weigh these five factors before deciding to make a psychiatric condition known on the job:
  • How supportive is the person you are disclosing to likely to be?
  • What type of culture does the company have?
  • Do you have a proven track record?
  • What is happening in the society as a whole? “You probably don’t want to disclose after a mass shooting,” she said, when people tend to connect mental illness with violence. (this is literally a quote…TF?)
  • Do you need to disclose everything about the condition, or would it be better to be selective?
This Scientific American article also points out the potential risks of being open about mental illness in the workplace. “Historically, people who have revealed their mental illness at work have faced discrimination. For instance, in a 2010 survey of U.K. employers, about 40 percent said they considered hiring someone with a mental illness to be a “significant risk” to the company. Many employers believe that people with mental illnesses are difficult to get along with and unreliable. People with mental illness may be denied promotions and other opportunities for advancement. Even in supportive office environments, employees with mental illness sometimes feel increased scrutiny from their co-workers.”
Even outside the workplace–say, like, writing about it on your personal blog–there’s still more risk being open about mental illness if you’re of a certain age/generation where mental illness wasn’t something to be talked about openly. I struggle with it writing this now, and in terms of figuring out the balance between sharing openly to do my part to fight stigma and potentially damaging future job prospects. Because let’s face it–for as much “you go, girl” as there is about living out loud in this day and age of oversharing and being real–stigma and discrimination about people being “crazy” is still a fact of life, just as is the reality that potential employers routinely comb the social media profiles/postings of job candidates or current employees.
So what are those of us who are neither millionaire celebrities or teens who have yet to worry about workplace discrimination to do if we want to be open about living with mental illness? Just do it and hope that our employers are fine with it and that we won’t face any negative ramifications either in future business endeavors or by parents who don’t want their kids socializing with kids of a “crazy” person or whatever? Or decide that it’s not worth the potential loss of professional stature or, worst case, a job, and continue to perpetuate the very stigma that has put us in this situation to begin with by pretending that mental illness is something that only impacts teens or celebrities and that the rest of us are JUST FINE, all the time?
I guess like all things in life, the answer is probably “it depends.” But also–a lot depends on more of us “older” folks sharing our stories if we ever want to live in a time when not only the young or the rich enough feel safe/empowered enough to get be real about mental illness.
  
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I am constantly getting calls from AFLAC representatives that want us to offer their critical illness coverage to our staff. Usually, they try to bribe their way in the door with one of those silly ducks—that's a great marketing approach if your target audience is three years old or a canine. (I hear dogs love the stuffed ducks.) Recently, a rep tried a different approach. She tried to guilt me into offering ASHA employees the opportunity to choose. Choice is a fundamental American value. Why was I denying ASHA staff the right to choose for themselves?

It's true, ASHA staff value the opportunity to choose, but they want to choose between good options. They trust me to vet what we put in front of them and I'm not going to let someone sell my colleagues swamp land. 

I did a little research online and talked to a source who shall remain nameless. The average annual AFLAC premium is $780/year. The seller makes 47% commission in the first year or over $366. Stock bonuses can be earned on top of that. In other words, half of what you're paying goes in the sales reps' pocket.


No wonder the sales reps are so persistent. You'd think they'd be trying to get their foot in the door with a nice bottle of wine though. They can afford it. 

In general, I'm not a fan of critical illness insurance because the policies pay out only if you get sick or injured the "right way." Some policies only cover a cancer diagnosis for example. If you have a heart attack, you're out of luck. (In more ways than one.) However, I am a big believer in protecting your income with disability insurance. I wrote about our recent efforts in that regard in this post. But, don't just take my word for it. 
The coverage is surprisingly common. SHRM reported that 9 out of 10 critical illness policies are sold through the workplace. 45 percent of employers with more than 500 employees offer the coverage. Critical illness coverage has expanded as high deductible health plans have become more popular. These plans are marketed as a way to protect yourself against the deductible. I just don't think they are the best tool. I believe your money is better spent purchasing disability coverage and funding a health savings account. 

I'm sure there are polices out there that don't pay a 50% commission and that there are some employers that are carefully vetting the options. However, I've heard that there are employers that do offer the coverage don't handle it properly. If an employer allows the coverage to be paid for pre tax, it's an ERISA plan and you have to offer COBRA, File 5500, Report it on W2s, etc...

Because I have the utmost respect for Carol Harnett and think it's always worth considering another point of view, especially a well informed one, take a moment to read Survival Entails a Price

I like this quote from an article in the Economist on choice.
As options multiply, there may be a point at which the effort required to obtain enough information to be able to distinguish sensibly between alternatives outweighs the benefit to the consumer of the extra choice. “At this point”, writes Barry Schwartz in “The Paradox of Choice”, “choice no longer liberates, but debilitates. It might even be said to tyrannise.” In other words, as Mr Schwartz puts it, “the fact that some choice is good doesn't necessarily mean that more choice is better.”



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How much you believe in a need for universal health care is largely dependent on how much you see health as a common endeavor. The national policy debate we've been having lately and the health economics class I just completed have me giving it some thought.

Respecting people's preferences is an important tenet of economics. So, if you like to spend your leisure time watching football and eating pizza, we can presume that you know best what makes you happy and you alone suffer the consequences. If however, other people pay the price for your choices, then there is a social cost, and it is reasonable to consider some intervention.

There are many externalities associated with health that impact us all.
Each of these examples impose a social cost. If we acknowledge this and see health as a common endeavor, then we have an opportunity to address the issues together.

The attitudes of American's are evolving. According to a Pew Research polling data,
Currently, 60% of Americans say the government should be responsible for ensuring health care coverage for all Americans, compared with 38% who say this should not be the government’s responsibility. The share saying it is the government’s responsibility has increased from 51% last year and now stands at its highest point in nearly a decade.
One argument against universal health care is that health insurance does not improve health. The NEJM just published an article by Benjamin Sommers, Atul Gawande, and Katherine Baicker that reviews recent experimental and quasi-experimental studies of the ACA and other expansions of public or private insurance titled Health Insurance Coverage and Health -- What the Recent Evidence Tells Us

They conclude that "coverage expansions significantly increase patients' access to care and use of preventive care, primary care, chronic illness treatment, medications, and surgery." There is also abundant evidence that having health insurance improves financial security.


But, do these things improve people's care and not just how it's paid for? Yes, "insurance coverage increases access to care and improves a wide range of health outcomes." It comes at a cost though. You have to cover 239 to 316 adults on Medicaid to save one life. 

I started with a question and I'll end with a question. What's a life worth? There are current public policies that address workplace safety and environmental protections that average $7.6 million per life saved. Expanding Medicaid costs $327,000 to $867,000 per life saved. 






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I attended the Vox Unconference, the World Heath Care Congress and a pharmacy summit this spring. There was one topic that overlapped the three events--the opioid crisis. It's all over the news, but so frightening, I think it bears mentioning here. Here are some things you need to know--especially if you're a parent.
  1. The risk of continued opioid use increases after 4 to 5 days. If there is a history of addiction in your family, even that amount of time may not be worth the risk.
  2. Opioids are not effective for treating chronic pain. They may work for a month or so, but the effect is likely to diminish even at increased dosages. Eventually, you'll be left with your chronic pain and a drug dependency. Some people even experience hyperalgesia, a greater sensitivity to pain after taking narcotics for longer periods of time.
  3. How pain came to be the fifth vital sign. The New Yorker ran through a good history in Who is Responsible for the Pain-Pill Epidemic. Vox reported, "US doctors wanted to treat pain as a serious medical problem. But when pharmaceutical companies pushed opioid painkillers with a misleading marketing campaign, they started a drug crisis."
Vox did a really great story on the crisis: How the opioid epidemic became America’s worst drug crisis ever, in 15 maps and charts. Please take a few minutes to scroll through it and watch the 4 minute video.


Things are really bad. A few weeks ago CBS News reported, "For the second time this year, a coroner's office in Ohio has run out of space for dead bodies due to the opioid epidemic." The opioid epidemic was directly responsible for 33,000 deaths in 2015. There were 52,000 drug related deaths overall. Much of the illicit drug use began with the use of legitimate prescriptions for opioid painkillers. As the government cracked down on how opioids are prescribed, people who are addicted switched to heroin. Horribly, things seem to be getting worse, not better.

There is tons of good information available. Here are some recommendations if you want to explore this topic in greater detail.

















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As I write, I'm sitting under
our silver maple tree.
Tree At My Window by Robert Frost 
Tree at my window, window tree,
My sash is lowered when night comes on;
But let there never be curtain drawn
Between you and me.
Vague dream-head lifted out of the ground,
And thing next most diffuse to cloud,
Not all your light tongues talking aloud
Could be profound.
But tree, I have seen you taken and tossed,
And if you have seen me when I slept,
You have seen me when I was taken and swept
And all but lost.
That day she put our heads together,
Fate had her imagination about her,
Your head so much concerned with outer,
Mine with inner, weather.
We sleep with the curtains open because I like to fall asleep looking at our silver maple tree. I figured Robert Frost would approve, but there may be more to my peculiar trait. Simply being in the presence of trees reduces the stress hormone cortisol and increases your immune defense system. It's part of a national health program in Japan where they call it "forest bathing." You can get the gist of it in this short video from the World Economic Forum. 

What is Japanese "FOREST BATHING" by World Economic Forum - YouTube


I don't need any convincing, but I'm still adding Your Brain on Nature to my reading list. This is yet another good example of where wellness and environmental issues intersect and it presents a unique opportunity for me to include a poem on my blog. 

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42 out of 100 ASHA staff are worried enough about protecting their families to buy life insurance, but only 25 in 100 had individual disability income insurance. These coverage choices don't reflect the actual risk. We undertook an initiative to offer supplemental disability (aka individual disability income) insurance to all our staff that had not taken it at the time they were hired. Now 53 out of 100 have individual disability income insurance. This initiative more than doubled the number of people with coverage. 

People are far more likely to become disabled during their working years than to die. You hear all kinds of numbers thrown around. I looked at disability and death probability tables published by the Social Security Administration for insured workers born in 1996. Death is pretty indisputable, but disability is more subjective. The Social security Administrations standard of disability is high, so this gives us a conservative estimate of disability.
  • Males born in 1996 (so they attained the age of 20 in 2016) have a 26.3% probability of disability before age 65 and a 7.2% probability of death.
  • Females born in 1996 (so they attained the age of 20 2016) have a 24.8% probability of disability before age 65 adn a 3.6% probability of death.
You can calculate your personal likelihood of disability using this tool from the Council of Disability Awareness.  

Why are we far less likely to protect ourselves against the more likely event? Most of us cannot afford to live without a paycheck. Medical problems contribute to 62% of all personal bankruptcies filed in the U.S. and half of all home foreclosures. We’re lucky that ASHA insures 60% of our income for us, but the extra 15% we have the opportunity to buy can make a huge difference if misfortune strikes.  I assumed that many of my colleagues had not made a fully informed decision and worked with UNUM to offer supplemental disability (aka individual disability income) insurance to all our staff that had not taken it at the time they were hired. This was not easy. It took two years of hounding UNUM using every angle and connection I could muster to get them to agree. (A special thanks to Zack Pace at CBIZ and Carol Harnett at the Council for Disability Awareness for their help.) 

I met with the 205 people we extended the offer to and explained how they get paid if they can't work. I drew a timeline from that date to their 65th birthday and walked them through how family and medical leave, sick leave, annual leave, short and long term disability coverage work. 92 accepted the offer of coverage. Here's some of what we discussed. 
Can you live the way you want to live on 60% of your current salary? If the answer to this question is “yes,” you don’t need additional disability coverage. If the answer is “no,” keep reading. Our group policy that ASHA pays for insures 60% of our income. If you choose to purchase supplemental coverage, it raises your benefit from 60% of your salary to 75% of your salary.

What are your chances of becoming disabled? Probably higher than you might think. Just over 1 in 4 of today's 20 year-olds will become disabled before they retire. 
What are the most common causes of disability? If you’re healthy, you probably think of accidents first, but they’re not usually the cause of disability. Illnesses like cancer, heart attack or diabetes cause the majority of long-term disabilities. Musculoskeletal disorders like back pain, arthritis, spine/joint disorders, and fibromytis are also significant causes. Happier circumstances can also lead to disability for example, if a woman is placed on an extended period of bed rest when pregnant.

How long does the average period of disability last? The average group long-term disability claim lasts 34.6 months, so about three years. One in eight workers will be disabled for five years or more during their working careers.

How many years do you plan to continue working? In thinking about the value of disability coverage, your age matters because the typical benefit period is until age 65. That means you’ll receive disability payments from the time you become disabled until you reach the age of 65. If you’re between 65 and 75 when you become disabled, the maximum benefit period is 24 months. If you’re over the age of 75, the plan only pays you for 12 months. Once you reach retirement age, disability coverage may not be a good value. You might want to consider additional long term care coverage instead. 
It just goes to show you that people need help to make a fully informed decisions. We've changed our onboarding process and I now meet with every new hire to explain this covreage in particular and then we make sure that we get a decision from everyone so that they haven't set aside the informaiton and forgotten about it. With any luck, no one will ever need it, but I'll sleep better knowing everyone who wants the coverage has it. 



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Ian and I at a pro-choice rally
April 5, 1992
Half of pregnancies in the United States are unplanned. Maternal mortality is rising and much higher in the U.S. than in comparable countries like Canada and the United Kingdom. Maternity care and childbirth cost more in the U.S. than in the rest of the developed world. Yet, we are still debating whether or not health insurance should cover birth control and maternity care.

The Trump administration recently announced plans to roll back an ACA provision requiring insurers to cover birth control and the American Health Care Act would allow states to opt out of covering maternity care. Prior to the ACA, only nine states required maternity coverage and only 12 percent of plans available in the individual market place included benefits for maternity care. [Statistics from: How Obamacare changed maternity coverage.]


Instead of working to address the reasons behind appalling statistics like this, the Trump administration is trying to set us back even further.
In 2005, 23 US mothers per 100,000 live births died from complications related to pregnancy or childbirth. In 2015, that number rose to 25. In the United Kingdom, the number was less than 9. In Canada, it was less than 7. ~JAMA
There are many options for long acting reversible contraceptives available today, but some cost upwards of $500. It's a small expense in a health plan--especially when compared to maternity care and child birth which can easily hit $20,000. However, $500 out-of-pocket is out-of-reach for many young women. (Despite Tom Price suggesting all women can afford birth control.)

There is a definite link between unintended pregnancy and poverty. Medicaid paid for 68% of the births resulting from unplanned pregnancy. This makes it a public health issue that effects us all. Unplanned pregnancies cost taxpayers $21 billion dollars each year. Since the Accountable Care Act went into effect, the rate of unintended pregnancies has dropped and the abortion rate in the U.S. has fallen to the lowest level since Roe vs Wade went into effect. This progress is about to be undermined. 

The proposed regulation can go into effect as soon as it's published in the federal register. Typically, there would be a notice and comment period, but the Trump administration wants to bypass that process and have it go into effect immediately. In this way, the executive branch could set us back without any help from congress and without any public involvement. Some states are beginning to take action putting birth control on the legislative agenda, but allowing employers and insurers to opt out as the Trump administration is proposing is a giant step backward. 


Related reading:

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My mom practicing her balance
after completing 40 squats.
Meet my mom. Mom is 73 and she can out walk most of my friends. I'm always sharing exercise tips with her and Mom actually does the things I recommend. It started years ago when I suggested she stand on one foot like a stork when brushing her teeth. When that got easy, I sent her a half foam roller to challenge her balance. Balance is a key to preventing falls and broken bones according to the National Osteoporosis Foundation. Here's a simple routine anyone can follow

Mom will be adding interval training to her routine. My friend, Carol Harnett, recently shared this NYTimes article on the best exercise for aging muscles. It describes a study that looked at the types of exercise that have the most positive impact at the cellular level. As we age, the cells in our muscles do not regenerate as quickly. Exercise can help us combat this, but interval training has the greatest positive impact. 

What's this mean in practice? Mom is going to work hard on a stationary bike, elliptical or treadmill for four minutes, rest and go easy for three, and repeat three more times for a 28 minute work out. She'll throw in a few minutes to warm-up and set a goal to do this three times per week. And, because I want to be able to hike up a volcano in Iceland when I'm 72 like my mom did last year, I'll be doing the same thing. 

Mom and I plan to be "super-agers" just like these women on The Today Show who defy the effects of old age. In addition to being physically active, these folks are learning new things. They routinely push through the feeling of discomfort we all feel when we're exercising or struggling to learn something new. I'm taking a Health Economics class at George Mason University this semester. Mom's looking into taking one of The Great Courses online. (Following that link will get you a free month trial thanks to Ezra Klein at Vox.) 
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