Tuesday, November 30, 2010

Connecticut Blockbuster

Governor-elect Dan Malloy has appointed Justice Joette Katz to be Commissioner of the Department of Children and Families -- a Department with chronic problems that requires someone of exceptional talent and intellect, like Justice Katz. Why she would trade in the best job on the planet for this big a headache we may never know, but we are very lucky that she has agreed to do so.

Meaning now there's an opening on the state Supreme Court. I just happen to know a lawyer who's wanted to be a judge her whole life who could easily make herself available were Governor-Elect Malloy to ask.

Don't worry. It won't happen. Just a fantasy. Jennifer

Images Illuminate the Brain

Read ab0ut it here. I personally just like the pictures. Jennifer

Tuesday Morning News

The medical loss ratio rules allow states to apply for exemptions, at least in the short term, if they feel that the rules would destabilize the insurance market in their state. They're also one of the best ways to make sure consumers are getting bang for their buck -- the medical loss ratio is the percentage of each premium dollar that goes to pay for health care, so the higher that is, the less insurers are spending on administrative costs. Small insurers say this will put them out of business, and in some states where only a few insurers dominate the market, that could be a problem. However, the more waivers are granted, the fewer teeth the law really has. How to strike the right balance. (And by the way, I'm 71 pages into the 308 pages of MLR regulations so I'm not ready to say what I think yet, except I like what I'm reading a lot.)

And in a mess only the Congress of the United States could make, the Senate is failing to fix a really concerning provision of the health reform law. To raise some revenue to pay for the bill, Congress said that businesses have to file a form 1099 for every vendor to whom they pay more than $600. Right now, that rule only applies to services rendered. Now, it would apply to the office supply store, the printer -- every transaction over $600. As a small business owner, this makes me cringe. So if the Republicans hate health reform, why won't they agree to get rid of this? Because it will make people hate health reform even more come tax time. But in good news, it looks like the food safety bill will be passed today.

This is a really nice article about a doctor who treats chronic kidney disease and suffers with diabetes, so he gets what it means to live with chronic illness.

Flu shot or supplement or both to ward off the flu?

An entirely different type of health insurance, value based insurance. If it's valuable to your health, you pay more.

The use of CT scans is booming in emergency rooms -- increasing costs, and not necessarily making a difference in health care.

An increase in eating disorders in kids? Really?

California seven largest health plans are fined for not paying claims.

Do you take enough Vitamin D? Too much? I am a firm believer in the link between my Crohn's disease and vitamin D. I take a ton of it an can barely maintain low normal readings. If you have an autoimmune disease, have you looked into it?

Do you have a mini-med insurance plan? Is a plan that provides a very small benefit every year -- under $10,000 -- worth having, or does it cause a false sense of security?

Do your legs ache when you walk? You may have peripheral artery disease, and it needs to be taken seriously.

Here's to your health! Jennifer

Monday, November 29, 2010

Monday Afternoon Edition

Narcissism is being removed from the manual of mental health disorders. The one time the narcissists won't say "but it's all about me!"

Inefficiency in health care ranks US 49th in the world in mortality.

Science transforms skin cells into other body parts needing replacement. Here's a better explanation. Scientists "trick" cells into switching identity. The idea is that, eventually, if you need a new heart, they can take cells from your spleen and use them to grow you a new one.

The House of Representatives went along with the Senate in extending the deadline for major cuts in Medicare reimbursement rates for one month. One month. That means they have to take it up again even before the lame duck session is over. Whose idea was that, I wonder?

And that's it for today. Jennifer

Me in the Hartford Advocate

I was interviewed for this piece in the Hartford Advocate (a weekly, which is why it didn't come out until now) on the Anthem premium rate hikes. I appreciate that they got my position right. Insurers are mostly for profit. They will make as much money as they can. It's the regulators who have been lax in protecting consumers. The reporter got it -- and me -- right. Jennifer

The Back from Thanksgiving Edition

There hasn't been much health news the last couple of days. I suspect it will pick up as the day goes on. Here's what I could find this morning:

This worries me a lot -- taxing health insurance premiums. What happened to no insurance increases for the middle class? The idea isn't just to raise revenue, but also to make employees more frugal consumers of health care. They don't think copays and deductibles already do that? Won't this mean the end of employer-sponsored health care? Maybe that's not a bad thing. But for people like me -- who gets group insurance as a group of one -- don't have a choice since nothing else would cover my pre-existing condition. But it's super expensive, so I could get killed on taxes. Maybe this is just a bad dream and I should go back to bed.

New health care delivery models -- accountable care organizations -- will they really save money, or will larger health care conglomerates decrease competition and increase costs?

The military is looking to decrease health costs, perhaps by raising copays.

Probiotics have some advantage for kids.

Easter Seals has released a study that shows differences across every aspect of life for adults living with disabilities and their families. Among the study's findings is that seven in 10 adults with disabilities (69%) live with their parent(s) or guardian, only 17% live independently – compared to more than half of adult children without disabilities (51%). Furthermore, only 45% of parents strongly agree their adult child with a disability will always have a place to live; whereas, 75% of parents of adult children without a disability strongly agree.

That's it, folks. If I have time to check back later, I'll see if there's anything new. If not, see you tomorrow. And happy day back from Thanksgiving -- not. Jennifer

Sunday, November 28, 2010

Last Day of Semi-Vacaation (emphasis on Semi)

Negotiate your hospital bills BEFORE you put them on a credit card or start paying the bill.

The President says he's extraordinarily proud of health reform. So am I. I have pre-existing condition insurance plans to refer people to who don't have insurance.

600,000 per year die from second hand smoke.

Well, I was willing to work for you today, but apparently the press is not. That's all I have. I'm sorry. Jennifer

Saturday, November 27, 2010

Skipped a Day Edition

Sorry I skipped Black Friday. Here's a bit of Saturday news:

The courts may undermine health reform. If there's no individual mandate, insurers will start pushing back on covering pre-existing conditions, and from there, it all falls apart. Of course, if we had a public option that accepted everyone with pre-existing conditions, that would work -- but what are the chances of that happening? And here's more on this week's decision in Ohio denying the feds' motion to dismiss, with members of Congress signing on.

Beware of medical credit cards, with high rates and sharp terms.

Nobody ever listens to me. So someone finally had the idea to create incentives to hire disabled workers to reduce the rolls of Social Security disability. Now, add temporary disability and we'll really cut those numbers.

It's getting harder to find Medicare enrolled doctors.

That's all I can find today. Guess the serious news waits for next week. Jennifer

Thursday, November 25, 2010

Special Thanksgiving Edition

One of these days, I will sleep late and actually take the day off. In the meantime, here's a smattering of news:

The LA Times says the health insurance industry is NOT in favor of repeal of health reform. Not because they're altruistic, but because they want those 30 million new enrollees! What's that line? Politics makes strange bedfellows!

A study finds no improvement in patient safety at hospitals.

President Obama has ordered a review of human research guidelines to make sure all subjects have given informed consent -- truly informed.

How do you feel about your doctor typing on a laptop in the examining room? Not everybody finds it to be a welcome change. I, however, spend so much time trying to decipher handwritten medical records that I welcome anything that makes my job easier.

That's it for today. I hope you and your families have a wonderful Thanksgiving. Jennifer

Wednesday, November 24, 2010

If I can't have health care, neither can you!

Calls for health reform opponents to decline federally- operated and funding health insurance grow. Here's a poll saying voters want them to reject federal health insurance. Here's more on that poll. And here's America's largest labor union jumping on board.

And here's a risky strategy -- a health reform proponent introducing legislation to repeal the most popular pieces of health form, daring the GOP to vote in favor. I hope this doesn't backfire.

This is the calm before the storm, so be amused now, while you can. It's going to get ugly. Jennifer

Happy Day Before Thanksgiving

Tomorrow's Thanksgiving, and like most of the rest of the country, I'll be taking a break for the next for days. A real break, not a semi-break. As in you won't hear from me until next Monday. I need it bad.

But here's one more day's worth of reading for you before I disappear:

A new poll says Americans like health reform and would expand it, not repeal it. Is anybody listening?

Here's something I've been saying for awhile. High deductible insurance plans mean people skip medical care because they can't afford the deductible. As premiums climb and people increase their deductible to try to lower premiums, they end up unable to afford health care.

Heard about medical homes but don't know what that means and how they operate? Read this excellent piece by Arielle Levin Becker at the increasingly essential Connecticut Mirror.

Beware of health related websites. Some of them are selling your contact information to drug companies. Here's more on this story.

Here's an interesting article about health care in China. Their medical care is not keeping pace with the rest of their economy.

Here's an opinion piece about accountable care organizations. Are they fostering innovation or eliminating competition -- or both?

Do you watch your salt intake? You should, although most Americans don't.

And that, dear reader, is it for me. Have a wonderful Thanksgiving. If you have a job, health insurance, and turkey dinner, you have a lot to be thankful for. If you don't, well, we'll be here seeing what we can do to help you get through the tough times. You are not alone. Jennifer

Tuesday, November 23, 2010

Day 2 Semi-Vacation Edition

Well, Echo and Nicole are doing their best to give me some time off, but the phones are ringing and people keep needing help, so semi-vacation is as good as it's going to get. In the meantime, I want to make sure you're up to date on the goings on of the day.

The big news yesterday was the release of the medical loss ratio regulations. Remember medical loss ratio, the percentage of premium dollars that are spent on health care? The regulations tell us what gets included in health care, and what counts as administrative. The regulations are 305 pages long and I didn't read them yesterday, but they appear to track the National Association of Insurance Commissioners recommendations, which are very consumer friendly. When I finally read the whole thing, I will let you know if there's anything you need to know about. But in the meantime, you can read about them here and here and here and here. The rules do allow waivers for what are called mini-med plans -- limited benefit plans that only provide certain limited benefits and are not comprehensive in coverage.

In other news,

Parents may not be able to keep their adult children on their RETIREE insurance policies, so don't assume anything, says WaPo.

An annual global survey shows progress against AIDS. Great news. And there's indication that one of the AIDS treatment drugs, Truvada, may help prevent HIV -- even better news!

This is a great article. When I first got sick and they couldn't figure out what was wrong with me, they sent me to a shrink, thinking it was all in my head. The NY Times says that's the wrong thing to do. If your kid has a stomach ache, be persistent.

This is interesting. Seniors -- and why not those with chronic illness -- are using electronic health trackers to monitor their health care, sending relevant info to the doctor using high tech communications.

Be careful at Thanksgiving dinner. It's exactly the kind of meal that can bring on a heart attack.

So go easy on the gravy and heavy on the family. Unless your family stresses you out, in which case you have my permission to eat desert. Jennifer

Monday, November 22, 2010

Semi-Vacation Edition

The first day of vacation, and I can't bear the thought of leaving you without your morning reading. So here's a short edition of Monday news:

The NY Times says health reform is spurring mergers that will increase costs and decrease competition -- some of the very things it was intended to fix. These are called accountable care organizations. What they bring to the market remains to be seen, but it's worth keeping an eye on them.

Most insurance doesn't pay for non-acute home health care, so it's important to plan for care after coming home from the hospital.

And in opinion news, Al Hunt says no way will health reform be repealed.

How good are Oprah's health guests? Well, I haven't been on yet!!!

And how about a health-related gift for the holidays? Which one? Read here.

How do you feel about getting health care online? Here's a report.

Some states are actually weighing ending Medicaid. I can't imagine a worse thing -- to take healthcare away from the poorest of the poor, from pregnant women, from children.

Employers' health care costs rise about 6.9% this year. When does this ever end?

Do laptops harm your health? Read on.

A very important piece on the effect of Celiac disease (gluten intolerance) on brain activity.

And that, my friends, is it for the day. Or at least I hope I can keep myself away from my computer. Now, how about you step away from yours too! Jennifer

Friday, November 19, 2010


Mike Pence disagrees with Mitch McConnell. He says repeal of health reform is entirely possible by 2012. While continuing to claim that health reform represents a government take-over of health insurance -- a claim that could not be more false -- Pence says despite President Obama's veto, the House Republicans will repeal reform and put something else in place that controls the cost of health care without expanding the role of government.

The opponents of health reform haven't even taken their seats in the House yet and I'm already tired of hearing this. I guess I'd better get used to it, eh? Jennifer

The It's Friday! Edition

I don't know about you, but this was one of the longest weeks in history and I'm completely zonked. Still, the work goes on, so here's today's reading:

The NY Times explains how the Republican gains in State government will affect health reform -- and it's not pretty.

The food safety bill moved forward in the Senate yesterday. There will be debate, and then a final vote. It's looking good.

In California, PPOs get low marks for customer service. This is consistent with our recent experience with Anthem of California, which is giving incorrect instructions on how to file appeals. Glad to see somebody noticed.

If you have an FSA, you have to empty it by the end of the year. Here are some tips on how to do so.

USA Today says hospital errors are preventable, and suggests ways in which we might do better.

With the population of Baby Boomers aging, can we reduce the number of disabilities? Experts on aging say maybe.

The Wall St. Journal reports on a study that says that one of the major drivers of increasing health care costs is hospitals.

It looks like there's agreement on postponing the Medicare rate cuts for doctors, but only for one month, putting off to the next Congress what is an increasingly pressing problem requiring a solution.

And that's it for the morning round-up. Enjoy! Jennifer

Thursday, November 18, 2010

The So How Was Your Day? Edition

Senator McConnell says he's counting on the courts to declare health reform unconstitutional -- since he knows there aren't the votes to repeal it in Congress. Really? Because I just got an email from a woman who lost her insurance, and I was able to get her on the new pre-existing condition insurance plan in Pennsylvania for $238 per month. You want to take that away? You sure about that?

The perfect antidote? Dr. Pauline Chen's next wonderful essay about the role of nurses in health care in the future. As doctors -- especially primary care providers -- become more scarce, we talk about physician's assistants and supporting doctors who choose primary care, but Dr. Chen suggests that we should also be talking about the critical role of nurses -- as well as ways to beef up nursing education to prepare them to take on an expanded role.

And as if the authors of this study were watching me this week, there are new findings that women with increased workplace stress risk heart disease.

Former Surgeon General C. Everett Koop warns that AIDS is becoming the forgotten epidemic. Americans have become complacent, he says.

And on that note, I leave you for 12 hours, until 4:30 am tomorrow, when I will be right back here reporting on whatever else you need to know. Jennifer

Nice. Not.

The House of Representatives defeated a bill to extend unemployment benefits through the holidays. Merry Merry and a lump of coal.

We have a real dilemma in this country now. We have a deficit that's huge and growing, with interest rates through the roof. But we also have people in real need -- no jobs, no health care, losing their houses, even their cars. How do we strike a balance? Where is President Obama's balance on this? And how will that balance shift once the Republicans take back the House majority?

I'm scared.

Meanwhile, it really would have been the right thing to do to make sure people were taken care of through the holidays, no? How about we all forgo buying unnecessary gifts for overly-indulged friends and family and find a way to help our neighbors? The answers don't have to come from government, and they don't have to be big fixes. Helping one person at a time is good, too.

Think about it. There but for the grace of [fill in your choice of deity] go we all. Jennifer

SustiNet Post- Federal Reform

The increasingly essential Arielle Levin Becker at the Connecticut Mirror did her homework, exploring what role the Connecticut's plan for universal health care, SustiNet, will play in Connecticut now that federal reform has passed. Of course, the State budget deficit is a major concern, but there should at least be a large purchasing pool to help the State and at least some of its residents find more affordable, comprehensive health care. The Board has released several options, each of which has different fiscal impact. If you're a Nutmegger, don't miss this really important article. Jennifer

My testimony on the Anthem rate hike

Advocacy for Patients with Chronic Illness, Inc. provides free information, advice and advocacy services to patients with chronic illnesses nationwide in areas including health insurance. We represent hundreds of patients in insurance appeals each year, and work with hundreds of others to try to help them find affordable health care coverage. We appear here on behalf of the thousands of chronically ill citizens of the State of Connecticut who are enrolled in Anthem Blue Cross Blue Shield’s (“Anthem”) grandfathered direct pay plans.

Anthem has based its requested 19.9 percent rate increase on two factors: Health care cost and utilization, and underwriting wear-off. Although we are not actuaries, Anthem’s rate filing raises several serious questions that must be answered before the Connecticut Insurance Department (“CID”) decides whether to approve the requested rate increase.

First, Anthem’s statements regarding health care utilization directly contradict widely-quoted statements by Anthem’s parent corporation, WellPoint, Inc. Anthem states that “[h]ealth care costs and utilization are the two main drivers of increasing health insurance premiums.” Anthem’s actuarial analysis reveals that claims cost is growing at a rate of 12.5 percent.

However, WellPoint reported better than expected earnings in the third quarter of 2010 because health care utilization has decreased significantly. Wayne DeVeydt, chief financial officer of WellPoint, states that utilization has fallen as compared with last year for several reasons, including the expiration of COBRA benefits and lower flu-related expenses this year. Murphy, “Drop in care use boosts health insurer 3Q earnings,” Washington Post (Nov. 3, 2010). See also Helfand, “WellPoint and Aetna post higher profit in 3rd quarter,” Los Angeles Times (Nov. 4, 2010). “’People just aren’t using health-care like they have,’ said Wayne DeVeydt, WellPoint’s chief financial officer, in an interview Wednesday. ‘Utilization is lower than we expected. . . .’” Johnson, et al., “Americans Cut Back on Visits to Doctor,” Wall St. Journal (July 29, 2010).

Thus, Anthem’s basis for the majority of the requested rate increase is directly contradicted by WellPoint. Anthem should be required to explain this obvious discrepancy.

Similarly, in light of these trends, one must question whether Anthem’s claim that underwriting wear-off results in claim costs that are 30 percent higher in year two than in year one. In light of the sluggish economy, it is well accepted – including by WellPoint – that consumers are forgoing elective procedures, and that this may not be a temporary trend. “’[T]his could go beyond the recession. Being a less aggressive consumer of health care is here to stay,’” says Paul Ginsberg, a health economist who runs the Center for Studying Health System Change. Johnson, supra. In addition, Anthem’s Lumenos plan is a high deductible plan, which forces consumers to bear more of the cost of health care, which also contributes to lower utilization. Id. In the second quarter of 2010, “WellPoint reported a 4% earnings bump, saying that hospital admissions and usage of prescription drugs had dropped compared with a year earlier.” Id. Thus, this trend has generated profit for WellPoint for at least two quarters in a row this year alone. We question the claim that this universal downward trend in utilization reverses itself once a consumer enters the second year of coverage under a policy.

Thus, the two assumptions upon which Anthem bases its rate request are questionable at best, even according to Anthem’s parent corporation. However, the problems with Anthem’s rate submission do not stop there.

There is considerable relevant information missing from this rate filing. In April 2010, the United States Department of Health and Human Services issued a request for comments regarding Section 2794 of the Public Health Service Act, which is the federal health reform provision regarding premium rate review processes. 75 Fed. Reg. 19335 (April 14, 2010). Many comments were submitted; among them were comments from WellPoint, signed by Elizabeth P. Hall, Vice President of Public Policy at WellPoint. Those comments suggest that States require an actuarial memorandum including all of the items included in the Anthem filing PLUS two additional items:

· A brief description of the type of policy, benefits, renewability, general marketing method and issue age limits; and

· An outline of recent prior rate increases and the effective date of the increases on each policy form.

Although WellPoint suggests that these items be included in rate filings, inexplicably, neither is included here. They are extremely important.

First, Anthem appears to take the position that all of the actuarial analysis that is provided pertains to all of its Direct Pay plans. However, intuitively, this does not make sense. For example, the Century Preferred Direct Pay plan can be purchased with or without a prescription drug benefit. The pharmacy utilization trend is a factor that is used to justify the rate increase. Clearly, it does not apply to a plan without a drug benefit. Similarly, Tonik is a very different type of policy than Century Preferred, and Lumenos is a high deductible plan that accompanies a health savings account, which, as noted above, is likely to produce very different incentives to utilization than the other plans. Indeed, the only thing all of these plans have in common is that they are individual policies. It is clear even from Anthem’s filing that the analysis of cost trends is very different between PPO and HMO plans. While we understand the preference for aggregated rate-setting, this approach requires that the nature of the plans be described so that the CID can ensure that the appropriate plans are being aggregated.

Second, since Anthem relies so much on underwriting wear-off, it seems quite relevant to know how many policies are in their second, third, fourth, etc. policy years. This information is not provided.

Third, the history of rate increases on these plans is very important. It matters whether last year’s increases also were in the double-digits, for example. If high increases are requested year after year, rendering these products increasingly less affordable, this trend is important not only to consumers, but to CID, which should, among its obligations, ensure that affordable individual plans remain available to consumers. The CID should require at least a three-year rate history to be included in any rate filings.

WellPoint also recommends that rates be filed 140 days prior to their effective date. This does not appear to have been done here, though. Further, WellPoint suggests that the actuarial review take into account the “impact of the mix of population covered based on demographics (e.g., age, gender, contract type, duration of policy, area and health status)”; and the “impact of benefit mix (e.g., percentage of members at each deductible level and product type).” Again, if these were taken into account, they are not shown in Anthem’s filing.

Other valuable information is excluded from Anthem’s rate filing. For example, it would be helpful to know the amount of Anthem’s surplus and reserves related to these plans. Although Anthem indicates the average monthly premium, it does not report how rates differ among the various plans, or even whether the requested rate increase would apply to all plans or only some, at the same or varying degrees. Indeed, we do not even know what costs Anthem includes in the medical loss ratios reported in the rate filing.

Perhaps most significantly, there is no indication whether Anthem intends to change the benefit packages under these plans. Despite the fact that these plans are grandfathered, the grandfathering rules do not preclude any and all changes in benefits packages. 45 C.F.R. § 147.140. Will the rate increases allow Anthem to maintain current benefit levels, or will Anthem reduce benefits while increasing rates?

Above all else, rate filings should be striving for maximum transparency to allow for meaningful public participation. As we move into the post-reform era of rate review, the CID should require all insurers to provide affected insureds with notice of the rate filing and the date and time of the hearing, and ensure that their rate filings are sufficiently informative and detailed so as to allow the public to understand them. Here, Anthem has provided less information than even its own parent corporation recommends, and nowhere near as much as the many consumer groups that filed comments in response to the HHS notice would prefer. Anthem should be required to revise the filing to provide all of the information that WellPoint agrees should be included in rate filings.

In sum, we have several substantive questions that should be answered before Anthem’s rate request can be ruled upon. Thus, we urge the Department to postpone a final decision on this rate request until all of these questions have been answered to the Department’s – and the public’s – satisfaction.


In my oral testimony, I stressed that, for Advocacy for Patients, this is not about Anthem vs. Aetna vs. United Healthcare. Our goal is transparency and public participation in the rate review process. We would support that goal regardless of which insurer's rates were at issue. Jennifer

Thursday Themes

Yesterday, Center for Medicare and Medicaid Services (CMS) Chief Donald Berwick finally testified in Congress. You may recall that he was recess appointed, so Congress didn't hold hearings on his nomination and they've been itching for a chance to question him. Dr. Berwick is a true innovator who advocates paying for quality performance rather than paying for services regardless of out come. Dr. Berwick pushed quality of care and defended health reform as a cost cutter.

Here's a short piece in the Wall St. Journal showing that the average deductible has increased substantially, to $1200 from about $770 five years ago. Interestingly, at yesterday's Anthem rate hearing, they said their average deductible is about $1700. This is what people do when premiums get too high - they agree to a higher deductible, and then they don't get care or amass debt because they can't afford the deductible, copays and coinsurance.

Politico reports that Democrat Ron Wyden and Republican Scott Brown are introducing legislation that would allow States to opt out of health reform's individual mandate. The law already allows States to apply for waivers of the mandate starting in 2017 if certain conditions are met. The argument here is that Oregon (Wyden) and Massachusetts (Brown) are already innovating around health care and should be allowed to apply for a waiver earlier, in 2014, if conditions are met. The exact conditions are fuzzy, but Massachusetts already has universal healthcare with an individual mandate, so this is not about Massachusetts. Wyden is generally well-meaning, but I hope this sort of step doesn't start reform on a path to unraveling.

There's concern about the food safety bill, which is stuck in the Senate. The delay appears to surround Senator Diane Feinstein's attempt to get a ban on BPA in food packaging (mostly plastic water bottles, as I understand it). Others would just like to vote on the bill as passed by the House so that its protections will kick in.

And I'm watching this study on whether chronic fatigue syndrome is linked to a retrovirus called XMRV. So many chronic fatigue sufferers are told it's all in their heads and there's nothing wrong with them. Wouldn't it be something if it were tied to a retrovirus -- and hopefully, that would mean that it could be treated eventually, as well.

And in Arizona, the budget cuts include money for organ transplants. Really? So there's something more pressing than life and death?

And finally, Democrats are asking anti-reform GOP-ers to forgo government-run, government-funded health insurance. It would be nice if the GOP-ers just said "point taken," but I doubt they will respond at all.

And that's what I've got this morning. I suspect I'm missing something -- after all, I did work until 9:30 pm and I started this at 4:30 am, so I'm a little tired! -- so check back later for an update. Jennifer

My Day At the Insurance Department

Yesterday was a hearing on Anthem Blue Cross's request for a 19.9% premium rate increase. In Connecticut, rate hearings are not required, but there was a hearing last year on Anthem's rates, which resulted in the rate increase being not quite as large as was requested. This was the first post-reform rate hearing. Since the Insurance Department has accepted $1 million in federal funding to revamp their rate review process, I sort of looked at this as the first real rate hearing in Connecticut.

The public testimony was devastating. One man afraid of losing his business because of the cost of health insurance. One woman who's not going to be able to afford to keep her insurance if these rates are approved. I testified about the fact that Anthem in Connecticut says it needs these rate hikes because of increased health care utilization, whereas its parent corporation Wellpoint says they're making record profits because of declines in utilization. I also said that the process needs to be more searching and transparent so consumers can have meaningful participation.

Anthem made the novel argument that, under health reform, if it turns out that the rates are too high because people really didn't use all the health care they anticipated, Anthem would then have a low "medical loss ratio" -- percentage of premium dollar used to pay for health care -- and would have to give rebates to members. Essentially, they said several times that there's no harm if their premiums are too high because it will all work out in the end due to the the law. Of course, that's no help to people who have to give up their insurance because of the rate hikes.

The Office of the Healthcare Advocate and the Attorney General's Office sought to intervene, and were allowed to cross-examine Anthem and call their own witnesses, which they did. They got Anthem to acknowledge that they're not paying doctors any more now than they were a year or two ago, so the increased health care costs aren't because of increased reimbursement rates. They had an actuary differ with Anthem's approach of instituting an across-the-board rate hike across all types of individual plans (HMO, PPO, high deductible).

The hearing officer did not take a single note all day (there was a court reporter, but still). And there was a show of disgust by a group of consumers who stood holding signs like "shame" while Anthem testified. In the end, I did not feel like any of it made much of a difference. I suppose we'll see what the result is. Anthem has until November 29 to submit some additional information the Department requested. So we'll have to see what happens.

All in all, though, this didn't seem like $1 million worth of process, transparency, and public participation to me.

Anyway, here's the Hartford Courant story. But here's the Connecticut Mirror story and the CTNews Junkie story, in which I am quoted.

Interesting day. I learned a lot about how not to do rate review. Jennifer

Wednesday, November 17, 2010

Hump Day Edition

I'll be spending most of my day today at the rate hearing on Anthem's newest rate hikes. I'll be testifying on behalf of consumers, making two main points. First, Anthem says it needs to raise its rates due to higher health care utilization. However, it's parent corporation, WellPoint, has said over and over that it's profits this year are due to reduced utilization. So not exactly consistent. Second, there's a TON of important information missing. In fact, WellPoint submitted comments to the federal government on what should happen at rate review hearings, and Anthem hasn't even done what WellPoint says it should have done. We'll see what happens at the hearing, but it could be most of the day.

Anyway, just so you don't feel lost without me, here's an early morning news round-up:

Hearings start today for the expansion of the Americans with Disabilities Act, seeking to use technology to accommodate people with disabilities and move beyond wheelchair ramps to new and challenging ways of making our society more accessible. Very exciting.

Coping with the stress of a medical emergency -- the patient (or her family) gets angry, the doctor gets angry, and things just fall apart. How can we do better?

Remember newly-elected health reform opponent Congressman Harris, who complained that he will have to wait 28 days for his new government-run health care to take effect? Well, Representative Crowley (D-NY) says all of the Republicans who oppose government run health care for their constituents should decline it as members of Congress.

The Center for Medicare and Medicaid Services launched its promising Center for Medicare and Medicaid Innovation yesterday. This is one of the most exciting pieces of health reform -- an office dedicated to finding new types of delivery systems that help control the costs of care while improving quality. They will focus on things like patient centered medical homes -- and innovations so new that they don't have names yet. These innovations will be public-private partnerships, with the government encouraging private sector stakeholders to try new ways of doing business in health care. We may not know what will work to control costs while maintaining quality, but this Center should help us find out.

Speaking of which, one experiment -- daily check-ins by phone for heart patients to try to maximize health and minimize hospital readmissions -- has been found not to work very well. A "good, commonsense idea" that simply didn't work. On to the next experiment.

Here's an opinion piece by Republican Senator John Barasso saying we should use GOP ideas to fix reform -- get rid of the employer mandate, the individual mandate, eliminate the Independent Payment Advisory Board (which is supposed to role on which treatments are cost effective -- a critical piece in controlling costs, unless controlling costs isn't your real goal), and eliminate an arcane piece that Democrats already agree needs to go, which would require additional 1099 reporting by small businesses. The employer mandate only applies to large employers to avoid them from dropping insurance and forcing employees out onto the Exchanges. And as I've explained a thousand times, how do we convince the insurance companies to cover everyone with pre-existing conditions unless we push healthy people to buy insurance, too? There doesn't seem to be a whole lot of meat here.

The Governor of Montana asks permission from the federal government to allow anybody to buy drugs through the Medicaid program, where the cost of drugs is very low due to government purchasing power. Right now, Congress doesn't allow Medicare to negotiate the price of drugs, but Medicaid can and does, and it's way less expensive. So let anybody buy through Medicaid?

A study finds wide disparities in late stage cancer care, in the number of patients going to hospice or who died in the hospital, who got chemotherapy very late in their illness, who got feeding tubes and CPR. Those in metropolitan areas got more treatment, but is that necessarily a good thing?

Meanwhile, health care sector CEOs are raking it in, says the Wall St. Journal.

The FDA has approved the first new drug for lupus in many years. A great breakthrough for lupus sufferers.

The hardest decision -- do you choose treatment no matter what?

Pot smokers who start before age 16 are most likely to develop cognitive deficits. No comment.

How to deal with job stress so it doesn't harm your health, from the LA Times.

Don't be so fast to give your kid antibiotics for a garden variety ear infection, says USA Today.

Wow -- busy news day today. Read on! Jennifer

Tuesday, November 16, 2010

Tuesday Morning News Round-Up

Lots of news today. Get reading:

With Congress back in session, you're going to hear a lot about a couple of issues, one of which being Medicare physician reimbursement rates. Some time going back at least a year -- long before health reform -- Congress decided to cut Medicare reimbursement rates by 23%. The new rates never took effect because doctors threatened to walk out of Medicare. But Congress has never permanently undone the rate cuts; they just keep putting it off for a few months at a time. Well, the cuts go into effect on December 1 unless Congress acts before then. Can a lame duck Congress deal with this issue? Will they find a way to at least delay it again? The Wall St. Journal tells us what happens if they don't.

Donald Berwick, head of the Centers for Medicare and Medicaid, makes his first trip up to Capitol Hill this week. Dr. Berwick was recess appointed, so Congress has never had a chance to grill him. I hope he's expecting an assault. It's not going to be pretty.

And here's a story about two states that already have insurance exchanges and how they work. They're popular, but not simple.

The Catholic Bishops maintain that health reform will allow federal funding for abortion -- but they can't come up with a single example or even a scenario in which this could happen, leading many Catholics to break with the church on this issue.

What's it like for a doctor to care for the President of the United States? Well, here's a little insight for you. Sounds pretty cool to me.

Jane Brody says it's important to check in on the quality of life of patients with chronic illnesses. When was the last time your doctor asked you how your illness affects your social life?

Do you get the wintertime blues? Doctors say it's real, and you need light in the morning. Worth a try?

Did you know most insurance doesn't cover maternity care? Or at least individual plans ( as opposed to group plans)? I didn't, but that's because I live in a state that requires maternity care.

And here's an interesting one. Defibrillators don't help much in hospitals, but they do in other settings.

In related news, a study shows that hospital care is fatal for as many as 15,000 Medicare patients per month!!!

The Chamber of Commerce (no, not your little local Chamber of Commerce, but THE CoC) is continuing its lobbying against health reform.

And here's a web-based registry of adverse events. Do you think doctors want to make it easier to report their mistakes? Will they do so?

I don't know about you, but I just have to laugh at things like this. A GOP House freshman wants to know why his health insurance takes a month to kick in. He just so happens to be against health reform. I think we should hold up his insurance longer than a month. What do you think?

And that's this morning's news! Jennifer

Monday, November 15, 2010

Monday Morning Round-Up

Today's my dear friend Laura Trafton's birthday, so we know it's going to be a good day. Here's some lesser news:

Snuggling with your cell phone may not be very smart, says the NY Times. Radiation exposure.

The Medicare doctor cuts were passed at least a year ago -- way before health reform -- and have been postponed a few months at a time, over and over. But now we have a lame duck Congress that has to postpone them again if they are not going to take effect on December 1. Can Congress get this done?

Then again, that's small potatoes compared to the big fight Republicans are gearing up for, says the LA Times.

Here's a pilot plan, nurses making house calls. Nice idea. Medicare as innovator. Expect to see more of this. Indeed, here's a plan in which doctors make house calls.

The Wall St. Journal tells you all you need to know about Medicare changes this year.

And in the truly bizarre, judges who hear Social Security appeals face violent threats. Really?

And Glenn Close speaks out for getting rid of the stigma around mental illness.

That should start your day off! Have a good one. And Happy Birthday Laura! Jennifer

Saturday, November 13, 2010

Saturday Bits

The cost of diabetes care is huge -- and only 25% of patients get the treatment they need, reports our favorite NY Times writer, Walecia Konrad.

More about the new report on the uninsured. One in every 4 Americans was without health insurance at some point last year.

Employers are creating incentives for employees to get healthy -- stop smoking, lose weight. But they want to see results before they reward you.

Democrats will work on repealing one of the sticky little problems in the health reform bill. The bill would require small businesses to report on every vendor to whom they paid more than $600 per year -- so the office supply store, the printer, etc. This has to go -- we've known this for awhile -- but the reason it was included is because it is expected to generate revenue, so we need to find the revenue somewhere else. That's the hard part.

I'm going back to bed! Jennifer

Friday, November 12, 2010

Finally Friday Edition

Minnesota Governor and Presidential hopeful Tim Pawlenty steps up his opposition to health reform by seeking to file a "friend of the court" brief in the pending Florida case. Here's more on this. He's challenging the Medicaid expansion because, he says, eventually, some day, way down the road, states MAY have to foot the bill. The federal government pays the costs to start with, but Pawlenty says there's no guarantee that the States will not have to pay for some of it down the road -- AND, of course, none of this happens until 2014. Sounds sort of speculative, but Pawlenty has vehemently opposed reform all along, and since he wants to be President, he's happy to make headlines, even if his concern is entirely speculative.

Here's a good explanation of how the insurance Exchanges will work in 2014 (if the law isn't gutted before then) -- marketplaces where you will be able to shop for insurance just like you shop for . . . travel? So says the LA Times.

But will the law make it to 2014? Politico says the GOP is recruiting conservative Democrats to oppose the law and chip away at it.

In lighter news, the Northeast tops the list in a study of well-being. In fact, Connecticut is number 1 in well-being in the country! Of course, we here already knew that. Where does your home state fall on the list?

Food nutrition labels are in for an overhaul, making them simpler to read and understand.

This is really alarming. Most girls don't get the full course of vaccination against the HPV, a sexually transmitted disease that can wreak havoc, but can be prevented by the vaccination.

Here's an article about the most difficult conversation of all -- what to do when an elderly person expresses a wish to die.

And here's a really interesting article from the Wall Street Journal about medical ethics -- how do doctors feel about assisted suicide? Romantic relationships with patients?

And finally, several important pieces on the mental health effects of war and what our veterans are going to need from us in the way of support and treatment. The stress of combat of course affects home and family life. Meditation may help.

And that's Friday's round-up. Have a great day. Jennifer

Thursday, November 11, 2010

Thursday News Bites

The number of uninsured adults in America has hit a record high - 50 million and counting. This isn't just bad for them; it's bad for all of us because, when they get sick, they end up in an emergency room and the taxpayers foot the bill. Bringing down the cost of health care is critical, but so is expanding coverage, and this is what health reform is good at. In 2014, with expanded Medicaid, subsidies for people up to 400% of federal poverty level, and the Exchanges all making care more available and affordable, we should cover at least another 30 million people. That's if we hang in until 2014 and don't dismantle the legislation before it can do the most good.

And Congress has a lot of health-related work to do besides health reform. Medical malpractice reform is a priority for the GOP. Medicare reimbursement rates for doctors are set to fall by a huge amount unless they are postponed yet again.

In other news, ......................

Caregiving for veterans is a struggle for families. Veterans health care in general is becoming an ever larger issue as so many vets return from Iraq and Afghanistan needing our support.

And here's a moving article about efforts to make one's home the right place to die for a terminal patient.

Have you seen the new graphics the FDA wants to put on cigarettes to warn of their danger? Wow.

How about high-tech informed consent, where a computer tells you all about the procedure to which you are agreeing?

And here's a wake-up call about colon cancer from the Colon Club, a great organization.

How to dispose of your old prescription drugs, from USA Today.

And that's how the morning landscape looks. Have a good one. Jennifer

Wednesday, November 10, 2010

Give Back the Money?

Huffington Post reports this afternoon that Rep Pete Stark (D-Calif) is asking insurance companies to give back the exorbitant profits they've earned in the first 3 quarters of 2010.

I have a better idea. How about the insurance companies pay Advocacy for Patients for every insurance appeal we win?!!! Jennifer

Great Question

Should insurance cover weight loss programs? Dr. Judith Wurtman poses this important question. Many insurers will pay for bariatric surgery, but they won't pay for over-the-counter nutritional supports or commercial weight loss programs. Is this rational since people who have surgery typically lose more weight faster? Or should all plans designed to help people lose weight be supported by health insurance?

What do you think? Jennifer

Survey Says Employers Will Continue to Offer Health Insurance

Opponents of health reform have said that it means the end of employer-based health insurance -- that once the Exchanges (marketplaces) are up and running in 2014, employers will drop their coverage and send employees into the Exchanges to fend for themselves.

Not so, says a new study by Mercer (a not exactly liberal consulting company). Only 6 percent of 2800 large employers who were polled said they will drop their health insurance. Small businesses will drive employees to the Exchanges in larger numbers -- about 20% -- but that has been anticipated by the law all along.

So once again, here's real proof that what's good about the status quo will remain intact. Jennifer

Wednesday's News Round-up

And here we go, folks. Republican investigators are taking aim at health reform. You ready for an endless stream of Congressional hearings? This, while the CDC says nearly 59 million Americans lack health insurance.

Senator Mitch McConnell is joining the law suit against health reform as a "friend of the court." Oh, boy. Because the whole legal battle wasn't political enough?

Former HHS Secretary Tommy Thompson says there are parts of reform that are important to people that shouldn't be repealed, but he has several ideas about how costs can be contained.

However, in an effort to maintain the status quo where needed, HHS is providing waivers to insurers, employers whose plans are very limited so they will keep providing even that limited care for employees. These so-called minimed plans are thought to be better than nothing. Employers and insurers have to clearly inform employees about the plans' limitations. I'm not sure how I feel about this one; is something, however flawed, always better than nothing?

Some employers are instituting a tiered system whereby the more highly compensated employees pay more for their health care.

Health insurance profits continue to soar. They say it's because people are using less health care (because they can't afford deductibles, copays and coinsurance). However, in their rate filings, they are saying they have to raise rates NOT because of health reform -- they only say that to consumers, but when addressing regulators, they can't lie -- but because utilization is increasing! No joke. There's a rate review hearing in Hartford next week involving Anthem, and we will be raising this issue to see if they can explain the discrepancy.

And here's another kind of claim against Blue Cross of Michigan, which is accused of anti-competitive behavior, requiring providers who sign up with Blue Cross to charge other insurers a much higher reimbursement rate. This is known as "most favored nation" status. We'll see what the courts make of it.

Meanwhile, GE moves into health care.

And why patients are unhappy with their relationships with their doctors.

That's it for the early round up. Have a good one. Jennifer

Tuesday, November 9, 2010

Tuesday Morning News Clips

Well, we here in Connecticut finally have a governor, Dan Malloy and his super-fantastic running mate, Nancy Wyman. This bodes well for our State, but what about the rest of the nation?

More on how the GOP governors will affect the health law implementation. And here, as well. This makes me nervous, at least in part because it's going to be hard to keep track of what each state is doing if they all do something different. We will have to see how this plays out.

Meanwhile, the Supreme Court rejected a challenge to reform, although only because it had not come up through the lower courts first, as cases must. So this has very little significance.

More about premium increases in 2011. Just so we're clear, these are NOT because of health reform. I have been reviewing Anthem's rate filing here in Connecticut in advance of a public hearing. They admit that only 2% of the 19.9% increase they are requesting is due to reform. The rest is due to rising health care costs and utilization. I have a response to this that I will share with you when my testimony is final, but I just want to be clear that even the insurers, when it counts, are saying that health reform is NOT the driver of these rate increases. Indeed, this article explains that what's happening this year is pretty much the same as what happened last year -- before there was reform.

But because of high premiums, more people are opting for high deductible plans. But here's an article about how high deductible plans benefit insurance companies. I don't really get the urge to high deductible plans. If I'm paying a premium, I don't want to have to spend another $3000 or more before my insurer will start paying my bills. I wonder if this is one of the reasons for the calls I'm getting from people WITH insurance who are overwhelmed by medical debt. As the second article points out, it's certainly at least partly the reason people are skipping doctor visits. I know medical debt by people who are insured is at least partly due to copays and things insurance won't cover, but before you choose a high deductible plan, make sure you have a plan for how to pay that deductible if you end up needing health care.

And here we are again. Last June, Congress passed a 6 month delay in greatly reduced reimbursement rates for doctors who treat Medicare patients. Well, the 6 months is almost up. Doctors are (rightly) pushing for a longer-term solution. Can it get done in a lame duck Congress? Watch health reform get blamed for this when this arose WAY before health reform was passed, when Congress first passed these rate cuts. We cannot afford doctors to leave the Medicare system, so Congress needs to step up and fix this once and for all. But what are the chances? Too good an opportunity to blame reform, is my guess.

Should we privatize VA health care? Here are reasons why not, at least right now.

And here's a really interesting take, what the author learned about treating cancer at this years' TEDMED conference. The reason this is particularly interesting to me is that it's about seeing cancer as part of a system, not just a disease, suggesting that we need to treat the cause, not just the symptoms. I think this is very interesting. Some day, they are going to figure out that Crohn's disease is all about the immune system -- I'm convinced, as are a whole lot of patients who have more than one immune-related disease, and so we live the connections in a very real way. I'm excited at the prospect of medicine catching up to our experience.

A lot of big ideas today. Read, think, and comment if you like. This is all open for discussion. Jennifer

Monday, November 8, 2010

Don't Repeal;Fix

Reprinted from the November 3 Advocacy for Patients Newsletter:

I wrote this before the November 2 elections; by the time you see this, you will know whether Republicans have regained control of either or both houses of Congress. If they do, it will be, in part, due to opposition to the health reform law. Whether or not they do, there surely will be members of Congress advocating for repeal.

A lot of you don't like the health reform law, too. Each time I write something favorable about it, a few people unsubscribe to this newsletter!!! I understand your reaction. First, the new law has not been explained adequately to you. You are hearing all kinds of things and you can't sort the truth from the lies. I've tried to be a trusted source of information for you, reading every word of the law and the implementing regulations. But why should you trust me more than you trust FOX News or your member of Congress?

That said, I want to dispel a few of the rumors. First, there are no death panels. There is no public funding for abortions. There is no coverage of illegal immigrants. All of those things came up during the debate over health reform, and there were quite a few Democrats who needed those things nailed down before they would vote for the law. I promise you, those are plain lies -- period.

Second, we're all seeing our premiums increase again this year, and the insurance companies are quick to tell us that it's because of the health reform law. However, I've read a lot, and it's just not true. The Department of Health and Human Services, as well as an independent report from the Urban Institute, says the cost of the few pieces of reform taking effect now -- coverage of kids with pre-existing conditions, coverage of kids to age 26, new appeals procedures, preventive care without copay, etc. -- warrant an increase of about 1-2%. Roughly this same figure is used by consultants Mercer and Hewitt. Yet, health insurance premiums are going up at a rate of about 9 percent for large groups and up to as high as 47% for individual plans here in Connecticut. Nobody really believes that these huge increases are due to the health reform law. Indeed, we've had double-digit increases for each of the last 5 years, before the health reform law was in play. Why are premiums going up? Because health care costs are going up -- and possibly (this is my conjecture) because next year, insurers have to limit their administrative expenses to 20-25 percent of premium dollars, so they are better off if premiums are higher when that percentage (called the medical loss ratio) kicks in. What we know, though, is that it's not due to the new law. Indeed, Secretary Sebelius has demanded that insurers stop spreading the misinformation that these huge rate hikes are due to the new law.

But most of all, I think a lot of us are just plain scared. There's a lot in this legislation that we don't know is even there, not to mention understanding how it will all play out. Some of the rumors are really nuts -- that the law requires that we all be implanted with computer chips, which comes from the law's expansion of the Children's Health Insurance Program or CHIP!!!

One evening during the debates leading up to reform, I was watching a talk show when the woman who leads the "birthers" movement claimed to have a copy of the law in front of her. She cited to a particular page number and said the death panel section was there. I ran to look it up. Complete and total lie -- it wasn't there at all. Those are the lengths to which some people will go to defeat this law.

So how do you know who's telling you the truth and who's not? I don't want to say that you should take my word for it. Don't take anybody's word for it -- and that includes media that has a point of view. Just like MSNBC airs opinion programs that discuss the news that are very liberal/progressive, FOX News airs opinion programs that discuss the news that are very conservative. You hear good things about health reform from Keith Olberman and bad things about health reform from Glenn Beck. It's all fine as long as we all realize it's opinion, not fact.

If you don't have someone knowledgeable whom you can trust to give you the facts, then it's important for you to read and learn for yourself. Every single morning, I read the NY Times, Washington Post, LA Times, USA Today, Politico, Huffington Post, and sometimes the Wall St. Journal, as well as Kaiser Health News, which collects and summarizes health-related news every day (to which you can subscribe for free). Every morning, I post a summary with links on my blog, which you can find here. Don't just read what I write; read the articles to which I link so you know your source and can decide whether or not to trust it.

Here's the bottom line. The status quo is unsustainable. Health care costs are skyrocketing. Premiums are increasing by double-digits. We are spending more and more on health care, but we're not getting any healthier. We couldn't keep going without doing something.

There are two big issues: cost and coverage. To deal with coverage, we had to eliminate pre-existing condition exclusions. I think it's fair of me to assume that most of you favor this since most of you have a chronic illness that would make it impossible for you to buy individual policies in most states. However, the insurance companies said: We can't take on all of the sick people unless they are balanced out by healthy people. This, too, makes business sense. And in order to make sure that healthy people without insurance would come into the system, we had to require that everybody buy insurance. But in order to do that, we had to provide subsidies for people who can't afford insurance. And then we had to figure out how to pay for those subsidies. And so that's how addressing the coverage issue got to be so big.

And it's true that we have not yet really grappled with cost. I do believe that premiums will come down in 2014 and beyond. First, there are the medical loss ratios that I mentioned above, that limit the percentage of premium dollars that can go towards administrative costs. Those will go into effect sooner. But beyond that, when the Exchanges are up and everybody has insurance, the sick and the healthy will all be pooled together so that costs can be spread over a very large number of people. The more you spread cost, the less each individual is going to have to pay. That's why bigger employers spend less per employee than individuals or small groups. I believe this will work -- to an extent.

But we have not done enough to control costs. And so you are seeing and hearing about lots of pilot programs -- patient-centered medical homes, accountable care organizations, pay-for-performance, for example -- that are trying out different ways of paying for and delivering health care to see if we can reduce costs without sacrificing quality of care. At least some of those pilot programs are part of the health reform law. As we find things that work, those things will be implemented on larger scales until we are able to make a real dent in health care spending.

Is everything in the new law great? No, it's not. It's pretty unusual for everybody to be thrilled by any large legislation because legislation of this scope is arrived at by negotiation and compromise. I suspect that, even if Democrats were to control both houses of Congress and the White House, there would be amendments to the current plan. That happened with Social Security, Medicare, Medicaid, and CHIP, so there's every reason to believe it will happen here, too, regardless of which political party is in charge.

What we cannot allow, in my opinion, is a return to the status quo, in which health care providers and insurers keep raising prices while more and more people -- and particularly those with pre-existing conditions -- are squeezed out of the health care market entirely. My insurance has gone from $440 per month in 2005 to $1165 per month today. That's $14,000 per year, and that's not including deductibles and copays. Eventually -- sooner than later if things keep going at this pace -- I would not be able to afford either insurance or health care, in which case I would get very sick and die. I know -- because I know most of you -- that you'd be in a similar boat. Indeed, some of you already are there. We cannot be a compassionate society and limit access to health care to the wealthy. That is where we were headed. So yes, we may have to give up something, but the health reform law does not mean giving up quality of care. And at bottom, that's what really matters.

I know many of you will disagree. Others will have questions. Please feel free to engage in a dialogue with me by phone or email or by commenting on my blog. My contact info is at the bottom of this page. And read and learn for yourself; don't take anybody's word for it. Get educated. If you are a person with a chronic illness, it behooves you to understand health insurance since you will be dealing with it regularly for the rest of your life. There are great health reform tools at the nonpartisan Kaiser Family Foundation, for example, that will allow you to better understand what health reform means to you. But pay attention to your sources and try to understand whether they have a political bias. They may still be worth reading; opinions are interesting and important, but they're not hard news, and you need to know the difference.

Educated consumers are going to fare better, whether under the new law or some other scenario. So get educated. If you're comfortable relying on me -- you know my bias is that everybody should be able to get and afford health care -- fine, stick with these newsletters and my blog. If you're not comfortable relying on me, then either find someone else who you know for sure is telling you the truth, or do the work to become educated for yourself. But don't be taken in by people who are out to scare you into voting for them, or by media that pretends to be news when, in fact, it's opinion. The fear-mongering, misinformation campaigns do us all a great discredit.

Whatever happens on Election Day, this national discourse is not over. So become educated and take a stand for affordable, available health care for all Americans, and let's focus our attention on how to get there. Jennifer

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