Joel Howell1, John Ayanian2. 1. Division of General Medicine, Medical School, Department of History, College of Literature, Science and Arts and Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan jhowell@umich.edu. 2. Division of General Medicine, Medical School and Department of Health Management and Policy, School of Public Health, Gerald R Ford School of Public Policy, University of Michigan, Ann Arbor, Michigan.