Tuesday, August 31, 2010

Can You Spell Hypocricy?

Meanwhile, 7 of the 20 states that have sued to stop health reform from taking effect are taking the federal dollars anyway. 'Nough said. Jennifer

Health Reform's Public Image

Public opinion continues to slip for health reform, says Politico. As best I can tell, the main reason for this is that people don't understand it and so many politicians and media are running with misinformation.

For example, huge numbers of people still think there are "death panels" in the legislation. This is a complete fabrication. In an earlier draft, there was the ability of Medicare providers to bill Medicare for conducting end of life discussions with patients. This provision was dropped due to all of the public outcry, even though there never were going to be government officials deciding who lives and who dies. It was malarkey from the start.

There is a basic disagreement in America. Do we take responsibility for each other or do we not? Do we help the uninsured to become insured even if it means changes for all of us that are scary? Be careful about how you answer this question. There are plenty of politicians who are against health reform who also would dismantle Social Security and Medicare, or at the very least, privatize them.

If you want a social safety net for yourself if you get old and/or sick, you have to also favor the social safety net for others who are old and/or sick. Before you start screaming about big government, understand that, if you succeed, you not only will be taking something away from today's poor, old, and sick, but those resources won't be there for you if you need them.

There but for the grace of whomever/whatever go we all. Jennifer

Health Care on Credit

Should we be using credit cards to finance our health care? Are we doing so already? This article suggests that we do so only with lots of care and a clear understanding of what we're getting into. Jennifer

Mobile Medicine

The last time I had a post-op infection, the surgeon -- who was 2 hours away -- wanted to see the wound every couple of days. Rather than travel all that way just so he could look at it, I took a picture of it every day and emailed it to him. It was a great solution.

So I'm not surprised to hear that mobile medicine is being experimented with for certain kinds of things. Read here. Jennifer


Read this article about Dr. Donald A. Redelmeier. He's a fascinating researcher doing fascinating research. May stand some of your pre-conceived notions on their heads. Jennifer

Monday, August 30, 2010

Unemployed Seeing Rise in Healthcare Costs

No surprise to those of you who are unemployed: Insurance premiums and other health care costs are growing faster than the rate of inflation, forcing many of the unemployed to lose their insurance. Read about it here. Being an unemployed person with a $500/month insurance premium and a chronic illness creates a morass that none of us is ever prepared for. Jennifer

The Empowered Patient

A new book talks about how to become a more empowered patient without being so assertive that you alienate your health care providers. In my experience, this is a fine line to walk, but it can be done. It helps to have doctors who really understand what being a patient is like, though. Jennifer

Insurance and Clinical Trials

Starting in 2014, insurance will cover health care costs while patients are on clinical trials, says the LA Times. This will be a boon to research, as well as to patients with rare diseases. Jennifer

Saturday, August 28, 2010

PCIPs Off to Slow Start

HuffPo reports that the Pre-existing Condition Insurance Plans are off to a slow start. They say the reason is high premiums, and that's part of it. I think it's also because you have to go without insurance for 6 months to qualify. Still, for those who are applying, it's better than nothing, and nothing is what they'd have had otherwise. Jennifer

High Deductible Plans with HSA's

Read here to find the pluses and minuses in high deductible plans with health savings accounts. Jennifer

Friday, August 27, 2010

Comments on Regulations on Coverage of Preventive Care

August 27, 2010


Office of Consumer Information and Insurance Oversight
Department of Health and Human Services
PO Box 8016
Baltimore, MD 21244-1850

Dear Sir/Madam:

We are writing to comment on the interim final rules for group health plans and health insurance issuers relating to coverage of preventive services under the Patient Protection and Affordable Care Act (PPACA). We are health care providers and patient advocates with a special interest in digestive diseases.

We are very pleased to see that the PPACA is resulting in a concentrated commitment to providing preventive care consistent with the recommendations of the United States Preventive Services Task Force (USPST), the Advisory Committee on Immunization Practices of the Centers for Disease Control (ACIPCDC), and the Health Resource and Services Administration (HRSA). We strongly support complete and universal insurance coverage of immunizations, well-care visits, and the whole host of preventive measures recommended by the USPST, ACIPCDC, and HRSA. We write to express a narrow but important concern.

The USPST, ACIPCDC, and HRSA recommendations are written for the general public, and for the most part, do not include recommendations regarding the frequency of the preventive measure in question. The interim final rules state that, if a recommendation or guideline for a recommended preventive service does not specify the frequency, method, treatment, or setting for the provision of that service, the plan or issuer can use “reasonable medical management” techniques to determine coverage limitations.1 However, the Departments also state that utilization of preventive services will increase when they are covered with zero copayment or coinsurance. We urge the Departments to consider, then, how leaving the “frequency, method, treatment or setting” of the preventive care to insurers will adversely affect their utilization, especially in patients with a higher than average risk profile.

For example, the USPST’s recommendation for colorectal cancer states as follows:

[S]creening for colorectal cancer (CRC) using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary.
Colorectal cancer screening was given a rating or grade of A by the USPST.

Patients with inflammatory bowel disease, as well as those who have a history of polyps or colon cancer, have a higher than average risk of developing colorectal cancer. More often than not, we recommend a colonoscopy for most of these patients every one to five years, depending on the illness and circumstances. In addition, in this patient population, we believe that colorectal cancer screening colonoscopies should begin before age 50. Thus, while the USPST’s recommendations may fit a healthy patient, they do not fit a high risk population. Surely, this is the case with other diseases, as well. For example, a patient with inflammatory bowel disease, dysmotility, or other digestive disease presents a complex dietary picture and, thus, counseling for a healthy diet requires both specialization and additional time. Leaving the decision of whether to pay for a nutritionist versus a primary care provider, along with the number of visits and the complexity of those visits, to an insurance company simply requires us to remain involved in advocating for coverage for our patients. The interim final rules are not clear and specific enough to make coverage automatic.

Thus, we would urge the Departments to consider shifting the decision-making for high-risk patients, i.e., patients who already have at least one chronic illness or previous incidence of colorectal cancer or other disease for which prevention is sought, to the treating physician regarding the “frequency, method, treatment, or setting” for the preventive care. The treating physician should have to provide nothing more than a certification to the insurer that the patient is high risk. This allows physicians to ensure that patients who most need preventive care are getting the type and level of care they need; it ensures that patients will utilize this care because it will be free; and it provides some protection to insurers, who will retain control over “frequency, method, treatment, or setting” for other than high-risk patients.

Again, we very much appreciate the Departments’ effort to make preventive care accessible for all patients in need. We agree with the Departments’ approach, as well as with the general assessment that both the PPACA and its implementation through the interim final rules, will increase utilization of prevention, resulting in a healthier America.

Thank you.


Linda Aukett
Digestive Disease National Coalition

Andrew R. Spiegle, Esq.
Chief Executive Officer
Colon Cancer Alliance

LeeAnn Barcus
Vice President
United Ostomy Association of America
United Ostomy Association of Greater St. Louis

Jennifer C. Jaff, Esq.
Executive Director
Advocacy for Patients with Chronic Illness, Inc.
FN1 26 C.F.R. § 54.9815-2713T (a)(4); 29 C.F.R. § 2590.715-2713(a)(4); 45 C.F.R. § 147.130(a)(4).

Patient Centered Medical Homes

The move towards patient-centered medical homes is growing, and that's a good thing for the chronically ill. More care coordination, more patient participation, and lower costs. It's all good, as far as I can tell.

Read and listen here. Jennifer

End the Two-Year Wait

There's a movement afoot to end the 2 year wait for Medicare for people on Social Security disability. Although the deficit hawks will cry foul (intentional pun -- hawks, foul (fowl) -- get it?), it would be a huge advance for the disabled. I'm all for it.

If they want to rein in costs, how about providing temporary disability -- 6 to 12 months -- for people who are flaring, or who are having a major surgery, and who just need short-term help? There are a lot of people who get Social Security at a time of crisis and then stay on it because they're afraid they'll never get it again so they hold on tight. I like the idea of a streamlined application process and short-term disability.

I also like the idea of providing tax incentives for employers who employ disabled people in work-at-home opportunities. This would allow many of the disabled to get back to work. Because, believe it or not, most disabled people really do want to work. Jennifer

The Flu

The CDC has lowered its estimate of the number of people who will die from the flu, here. Good news. Jennifer

Concierge Medicine

Pauline Chen's column on concierge medicine. Should the rich be able to buy better medical care? What if the practice uses it to subsidize the care given to other patients?

I'm not sure how I feel about this -- except jealous. Jennifer

Thursday, August 26, 2010

Disabled and Unemployed

This from disability.gov:

Persons with a Disability: Labor Force Characteristics 2009 is the first news release focusing on the employment status of persons with a disability. The information in this release is from the Current Population Survey (CPS), a monthly sample survey of about 60,000 households that provides statistics on employment and unemployment in the United States. Some highlights from the 2009 data are - the unemployment rate for persons with a disability was 14.5 percent in 2009, well above the figure of 9.0 percent for those with no disability; and nearly one-third of workers with a disability were employed part time, compared with about one-fifth of those with no disability.

For more info, go here. Jennifer

MLR - yet again!

More on the medical loss ratio -- the percentage of premium dollars that is spent on health care delivery and quality. Why do I keep focusing on this? The new law says that 80-85% of premium dollars has to be spent on health care delivery, things that benefit consumers. The idea is to force insurers to reduce their administrative costs to make them more efficient and bring down premiums. If it succeeds, we will see premiums decrease over the next few years. And that's why the MLR is so critical. Jennifer

Selling Health Reform

It's been nearly six months since health reform became the law and still, half of all seniors think it has something to do with "death panels" -- a complete fabrication. Anti-reformers have been very successful in spreading misinformation and scaring people into believing that reform will hurt them in the long run, when it was the status quo that was really hurting Americans terribly.

Well, now, the White House and other allies are planning a counteroffensive, says the LA Times. It's about time. I've too often felt like a lone voice in the wilderness, buoyed only by occasional conference calls with groups in DC who simply aren't being heard in the rest of the country.

Health reform is far from perfect, but come the end of September, we will start to see some real changes -- coverage of kids to age 26, no pre-existing condition exclusions for kids to age 19, new rules about appeals of coverage denials, no lifetime caps and increasingly high (to phased out) annual caps on benefits -- a lot of really important changes that nobody opposes. I hope that, as these improvements become more real and people see how they are helping, public opinion will soften. That takes keeping an open mind, though, so I hope you will. Jennifer

Sick, but still making a difference

An amazing woman with whom I strongly identify, read here. Jennifer

Wednesday, August 25, 2010

Atul Gawande on Hospice Care

Atul Gawande is one of the more brilliant physician/writers in the health field these days. So when he writes a new piece for the New Yorker, I typically take the time to read it carefully. I have never been disappointed.

His latest is as brilliant as I have come to think he always is. It's particularly poignant for me at this moment because I learned earlier this week that a little boy I know who has been battling cancer with great dignity and grace for several years is losing his battle.

I hope you will read it. It will enrich your life, even as it saddens. And hopefully, it will remind you that, if you haven't made your end of life decisions and informed your family of your wishes, you should. Nobody likes to think about dying, but nobody lives forever. If you want to have something to say about HOW you die, then you need to think about and communicate your wishes.

Thanks, Lybba, for the link. Jennifer

Tuesday, August 24, 2010

Looking for Health Insurance?

Chronic Fatigue

If you have chronic fatigue syndrome, you are used to people -- including doctors -- constantly wondering if you're really sick, or if you're malingering because, on paper, there's nothing wrong. Well, read here about another new study that links CFS to a virus. Wouldn't it be great if all those nonbelievers in your life could be proven wrong with a simple blood test? Jennifer

End of Life

New York passed a law requiring doctors to discuss prognosis and options with terminally ill patients. Is this compassionate care or "death panels" revisited?

I believe that people know when they are at the end, and that they ask when they want to hear. When they don't ask, I'd hesitate to say. Can a one-size-fits-all approach work?

My mom told us for months that, as soon as she needed pain meds and would be too out of it to function, she wanted to die. She died the morning after her first dose of morphine. Quietly, she just stopped breathing. She lived the way she wanted and she died the way she wanted.

I think options and prognosis and all available info are really important for family members, and if the patient wants to know, then they surely have that right. But I think they have the right to not know, as well. Jennifer

Behind Your Back?

What does your doctor say about you behind your back? This story makes that a scary question. Jennifer

A Setback for Stem Cell Research

Read here. If you were banking on stem cell research to crack the code of your disease, you will have a bit of a wait, it seems. Jennifer

Monday, August 23, 2010

Medical Privacy

We've all read about hospitals and insurance companies losing a computer or some files. How should they have to deal with any such breaches of privacy? New rules may help figure that out. Jennifer


The health reform law says that the National Association of Insurance Commissioners would make recommendations about key aspects of implementation to the Department of Health and Human Services. But the NAIC is made up of insurance commissioners, many of whose departments are funded by the insurance industry, and many of whom are pretty insurance-friendly as a result. What will HHS do? Speculation begins. Jennifer

Sunday, August 22, 2010

Pay Attention

As sick as you may be in the hospital, you'd better be paying attention. Read here. I don't care if they think I'm a difficult patient. At least I'm still alive. Jennifer

Friday, August 20, 2010

Health Reform Brouhaha

I was on one of a long series of conference calls on health reform organized by Families USA yesterday. These calls have been going on for a long time. For those of us who are not based in DC, these calls have kept us up to date, educated us about various reform proposals, and helped us figure out how to explain the truth about reform in effective ways. Yesterday's call was about this last subject, messaging. With the six month anniversary of reform coming in September and a handful of changes taking effect then (or at the beginning of the next plan year after that date), the premise of the call is that we need to explain reform, educate the public, try to dispell some of the fears that are based entirely on misinformation and even lies, and fend off the calls to repeal the law. The presentation yesterday was by the Herndon Alliance, a public relations firm that focuses on messaging around health care and health reform.

All of the Families USA calls are closed to the media. However, there was no big secret in yesterday's call. The Herndon Alliance's most recent research is right on their website. So there was no conspiratorial attempt at pulling the wool over the eyes of the public, no secret compact to hatch a bunch of new lies about reform.

Most importantly, there was nothing new in substance. In other words, it was not the case that everybody decided that we need to change strategy to "sell" reform. The strategy since way before the law was passed has been to educate, educate, educate. But HOW you say things, HOW you educate -- the Herndon Alliance has done the focus groups and polling to help those of us who are not professional communications experts to stress the right things, to approach people the right way, so that our message about how the law is going to work really gets across.

Apparently, immediately after yesterday's call, somebody leaked the Herndon Alliance's presentation to Politico, which immediately published an inflammatory article stating that Democrats -- led by Families USA -- are retreating from the arguments we've made all along and taking up a new strategy. THIS IS FALSE. There was some discussion of how effective it is to stress the cost savings to families, employers, and the federal government, for example. The Herndon Alliance's research tells us that this isn't the most effective message point; people don't believe it, and it's too wonky. Instead, the Herndon Alliance suggested that we stress people's stories -- that we paint a picture of how people's lives will be changed by reform. That doesn't mean we don't believe that, in the long run, there will be cost savings. I was on the call, and nobody even implied that the cost savings and deficit reduction are any less true than we previously thought. It was about choosing the best message, not telling lies.

Politico spun the story in a very unfair way. First of all, there was not one single suggestion that anybody hide any facts, distort any facts -- this was not about telling lies, as Politico implied (and the comments to the Politico post are both wrong and absolutely brutal). Just as companies consult with advertising agencies, who conduct focus groups and opinion polls all the time, so, too, do political parties, and the various organizations that take positions on public policy. Does anybody think Politico has never conducted any kind of focus group or polling about how best to present its messages? Certainly, the Republican party, the insurance industry, and anti-health reform groups all talk about how best to craft the anti-reform message. Do you think someone casually came up with the idea to call it "Obamacare?" That was a concerted, deliberate strategy. So yes, those of us who are in favor of reform because we HONESTLY believe that it will improve the lives of many Americans also talk about how best to get the message across to the American people. There's nothing sinister about this. It's not about telling lies. It's about how best to tell the truth.

For example, I can tell you that, effective September 23, 2010 (or the first plan year after that date), children under age 19 cannot be excluded from insurance due to a pre-existing condition (with the exception being grandfathered plans, explained below). Or I can tell you about the phone call I got from a mom in Missouri who's trying to find insurance for her 14 year old little boy with ulcerative colitis and asthma who's been calling and calling insurance companies and they're telling her to not even bother applying because they won't take him with a pre-existing condition. I can tell you that, when she makes those same phone calls after September 23, 2010, she is far more likely to find answers. I can tell you that these insurance companies are hiding that fact from her now, but they won't be able to hide it after September 23, 2010. Isn't it more effective if I tell you that story than if I just tell you what the law says?

And that's all the call yesterday was about -- how to communicate the truth. It was not about bending the truth or pulling the wool over anybody's eyes. It was about how to talk about what are some fairly technical changes.

If you want technical, I can give it to you. Grandfathered plans are plans that existed in substantially the same form when the law was signed on March 23, 2010. As you will recall, President Obama kept saying that if you're happy with your insurance, you can keep your insurance. Nobody believed him then, but here it is -- grandfathering. If a plan existed on March 23, 2010 and it does not change copays, deductible, out-of-pocket limits, coinsurance, annual limits on benefits, or eliminate all the benefits to diagnose and treat a particular condition, then it is exempt from many of the changes. If you are happy with that plan, you can keep it exactly as it is. However, if the plan changes in one of these important ways, then it loses its grandfathered status and no longer is exempt from the health reform changes.

Now that you're asleep, perhaps you will appreciate it if I tell you that the woman in Missouri will be able to take advantage of the elimination of pre-existing conditions for children under age 19 after September 23, 2010 because she will be buying a whole new individual plan. As a new plan, it can't be subject to grandfathering. And perhaps more importantly, the way the insurers tried to hide this from her -- indeed, she expressly asked them, didn't this change under the new law? And they didn't tell her anything about September 23 -- that will stop the more we implement the consumer protections in health reform.

Is health reform perfect? Far from it -- and saying that is nothing new, either. But for those of us who are out here in the trenches, who can't afford focus groups and polling, and who want to be as effective as possible when we educate the public about the changes that will be taking place, organizations like Families USA and the Herdon Alliance help us to do our jobs at no cost to us. Sometimes wonky lawyers like me need to be reminded -- tell stories, don't just rattle off facts. That was the key message of yesterday's call. It was not about lying. It was not about changing strategy. It was just about how best to get out point across.

Shame on you, Politico, for distorting that. Jennifer

More Disabled File ADA Complaints

According to this report, disabled Americans filed more discrimination complaints than ever before. We've certainly noticed that people with disabilities are facing increasing scrutiny in the workplace. Missing work -- even when protected under the Family & Medical Leave Act -- and asking for accommodations such as working from home or extended bathroom breaks give employers a sense that we are less productive than others, so when it's time to cut the workforce, many of us are the first to go. I'm glad people are filing complaints -- but I'd be interested to know how many of those complaints actually get anywhere.

There's a big problem with the law for people with disabilities. If you cannot perform the "essential functions" of the job, even with accommodation, you can be fired and it's not illegal. So if your employer says presence in the workplace is an essential function and you say you have to work from home, you can be fired. I'm always nervous when an employee calls me and asks me if they can ask for work from home or a transfer or something relatively big like that. I hate the thought that people may hand their employers an excuse to fire them. And the truth is that most complaints of discrimination don't get anywhere unless you get a lawyer and file suit, and even then, these cases are so hard to win, especially in a bad economy when the pressure on employers is so great.

Between a rock and a hard place. The law is great when it works. For example, getting accommodations in school remains pretty easily done. And getting ergonomic workstations is pretty easy, too -- these are the kinds of things that employers are used to having to do, and they're not terribly expensive. But when the problem becomes being able to make it to work every day, or needing breaks, or needing to be transferred to a different shift or a different job -- these are far more difficult, and the right answer is rarely clear.

If you're in this situation, feel free to contact me at patient_advocate@sbcglobal.net and we can talk it through. Jennifer

Health care for the Homeless

In 2014, Medicaid will be expanded to include all adults under 133% of the federal poverty level. At that time, homeless adults will be eligible for health care. According to this article, the change can't come fast enough. Jennifer

New Book About Chronic Pain

We get so many calls from patients who are having problems with chronic pain. They can't find a pain management doctor (there's 1 for every 25,000 patients, so no wonder they're scarce). Their doctor won't prescribe serious pain medication, or all of a sudden, their doctor stops prescribing. Nobody believes them, and since pain is subjective, it's hard for them to prove they are suffering.

Well, if this review is any indicating, a new book by Melanie Thernstron really makes the case for treating pain like a disease. The author is a patient, and her personal story runs throughout. Sounds like a great treatment of a very tough topic. Jennifer

Thursday, August 19, 2010

Should Doctors Admit Their Mistakes?

Should doctors admit their mistakes, or is the fear of lawsuits just too much of a reason to keep quiet? The next installment of Dr. Pauline Chen's brilliant column here. Jennifer


Interestingly, there are 3 articles about pain treatment in today's NY Times. First, palliative care extends the life of a lung cancer patient. Second, Tai Chi helps fibromyalgia pain. Third, accupuncture helps to relieve pain.

It would be great if there were some real options for patients with chronic pain that do not involve long-term narcotic use. Jennifer

Wednesday, August 18, 2010

Weight Part 8

I started today's session by talking about a couple of disability insurance appeals I'm working on. In both cases, the chances of success are slim to none. I've read the medical records. I have a Crohn's patient in remission worrying about what if, and a chronic pain/fibromyalgia patient who has a lousy rheumatologist who hasn't documented any trigger points, and who is not accepting any standard treatments, choosing instead accupuncture, herbal meds -- things insurance companies think are basically worthless.

The fibromyalgia patient has my attention today. She's 29 years old. She shouldn't give up. She can't give up.

I can't give up.

And so I go down the road of talking about how driven I am, how I would push myself through any health crisis, as I have done, working full-time even when truly deathly ill. I always had the feeling that, if I stopped, that would be it. It would all be over. Stopping for me means giving up. And giving up is not an option.

And so I close my eyes in search of an explanation for why I drive myself so hard. (For an explanation of guided imagery, see Weight Part 5, below).

The little girl wants nothing to do with this conversation. She used to be in motion all the time. My clearest recollection is of her building a brick wall. She was doing it to keep her family intact. She worked so hard, and it was all out of fear. Her mother would die without her. Her father would fall apart. She could not stop. Stopping meant death to her. She had to keep her parents alive because she needed them in order to stay alive herself. Once I convinced her that I would take care of her, she no longer had to be afraid.

The teenager isn't really up for this conversation, either. She wore her intensity as anger. She was angry that she had to do all this work. She wanted to be taken care of. Once I convinced her that I would take care of her, she was able to let go of her anger.

And so I took on the driven-ness that propels me through life. Instead of fear and anger, the adult me has an insane level of intensity. I can't take time off. I can't work an 8 hour day. I can't let up for a minute. I have to push and push, no matter what. It's not just work. I have to go to the grocery store every Monday and Thursday morning. I have to cook my current diet on Saturday morning. I have to make sure all my meds are refilled at the same time of the month so I only have to go to the drugstore once. I have to return every call I get the day I get it. I have such rules for myself, such discipline. It's not healthy. It makes me exhausted. I work so hard at life.

In every area except one: Food. Food is where I let go. I do not push myself on my weight.

The driven-ness is the reason I can't be happy.

My spirit guide chants a mantra: Balance. Balance. Balance.

"I want you to take those words and plant them, Jenni." I'm so afraid I will lose them. Indeed, I feel like I already have. The driven-ness is the reason I can't be happy.

"Now, water them. Feed them."

Amazingly, the blueberry jam girl feeds those words for me. She usually doesn't stop eating, doesn't engage in the conversation. It's usually not entirely clear that she's even listening. But today, she fed those words for me. The driven-ness is the reason I can't be happy.


It took all of my will-power not to stop on the way home for junk food. But I made it. Jennifer

Note: Ellen is going on vacation, so we are taking a brief hiatus. I will try to check in with my self in the meantime. But if I don't post another Weight entry for a couple/few weeks, don't worry. I'll be back.

Health Care for the Unemployed

Not unexpectedly, the unemployed are struggling without the COBRA subsidy. Although many members of Congress support extending the Bush tax cuts for the wealthy, their concern for the deficit means no more COBRA subsidy for the unemployed. Priorities. Jennifer

MLR -- again

Under the new health reform law, insurers have to spend 80 or 85% of premium dollars on health care delivery and quality. This is called the medical loss ratio, or MLR. The intent is to limit administrative expenses so that premium rates come down. Thus, this is a critical piece of health reform.

Yesterday, the National Association of Insurance Commissioners voted unanimously to improve a definition of the MLR that appears to be relatively consumer friendly. Here's some more about it. Although the details are still fuzzy, it seems we may be moving in a productive direction. Jennifer

Tuesday, August 17, 2010

Grants to Cut Premiums

I wonder if the states will do a better job of controlling health insurance premiums now that they are getting grants from the federal government to help them do so. Jennifer

Losing Friends

How many friends have I lost to illness over the years? This article helps. Here's the longer piece.

I hear about these kinds of stories every day. It's very sad. I will never understand why people don't realize that, there but for the grace of whomever go we all. Jennifer

Skipping Health Care

Due to the economy, people are skipping health care, says the NY Times. No surprise. People simply can't afford the care they need, even if they have insurance.

I got a letter last week saying out of network services are going to be using a new fee schedule. I pay $1165/month for my insurance. That's $14,000 per year in premiums. The letter said "try in network doctors." I have. They almost killed me. The letter said "use preventive care." I would like to have a preventive colonoscopy, but nobody in network can get a scope through me, so it costs me thousands of dollars to have scopes. So I put it off. Just like everybody else. And that's with insurance that costs $14,000 per year.

I keep hoping that, when reform is in full swing in 2014, prices will come down and some sanity will return to all of this. Jennifer

Monday, August 16, 2010

Is Bigger Better?

Some companies are buying up all the health care providers in town. Is a bigger network always better? Read here. Jennifer

Health Care Costs Down?

According to this, health care prices may be starting to fall. Wouldn't that be a relief to so many millions? Jennifer.

Your Brain On Vacation

What happens to your brain on vacation? Here are some answers. Jennifer

A computer in every house

Everybody with a chronic illness should have a computer. According to this study, they don't. Jennifer

Sunday, August 15, 2010

States: Get to Work

As reported here, state legislators have to get to work to give their Insurance Departments the power to enforce the new health reform consumer protections. Jennifer

Saturday, August 14, 2010

Insurance Coverage for Adult Children

Coming soon! Read here. Jennifer

Who's Your Pharmacist?

When I was at my sickest, I had a wonderful pharmacist named Eli. He got that I was juggling huge quantities of medicine. He saw how bad I looked when I could make it to the store to pick up, when someone would take me there because I was too weak to drive. He became a really important member of my care team.

Since he left, I've had a rotating cast of strangers who don't understand -- or care about -- my complex medical situation. It's made my job of self-management harder.

So, says the NY Times, pharmacists are getting and should get more involved in health care delivery. I'm all for it. Jennifer

Friday, August 13, 2010

Weight Part 7

It's been awhile -- my shrink was on vacation. However, I'm proud to say that I did start swimming two Mondays ago, as I had promised all of my inner selves (remember the guided imagery? If not, see Part 5, below. There's my little girl, the used-to-be-angry teenager, and now the blueberry jam girl, along with my spirit guide). I've stopped eating corn muffins for lunch most days. I have a couple of additional foods to eliminate over the next few weeks, and then I really will be at a point at which I will be eating very little, and if I still don't lose weight, I'll have to look into things like the effects of some of my meds on metabolism and things like that. But I've made real progress, changing habits and learning new ones that should work to my advantage in the long run, certainly for health's sake, if not my weight.

I've done a few other good things for myself in the past couple of weeks. My friend from camp Jan, who lives in Florida, was here yesterday and I took the whole day off and we went sight-seeing around Connecticut and had a really nice, relaxing, fun day. And I've started to make it clear to the Advocacy for Patients Board that it's time we moved out of my house. I'd like to be able to come home after a long day and actually be away from work, or take a day off but stay home if I want to. Starting to draw boundaries -- these are good things.

All that plus a huge accomplishment yesterday -- a medical device manufacturer is going to donate a special pulmonary vest to a 3 1/2 year old little boy based on a letter I wrote to the President of the company. I am so privileged to be able to help save a child's life, to do work like this.

We had a Board meeting the other night -- strategic planning. The exercise was to make a list of the internal issues that impact the organization. The first thing on everybody's list? Jennifer's health! A friend -- a FRIEND -- said that my health restricts the extent to which I can travel, which impacts the reach of the organization. The conversation went downhill from there. (And by the way, I've been to LA twice, Portland, OR, Seattle, Dallas, Chicago several times, Atlanta, and on and on -- I travel plenty). I finally reminded them that they could get sued for talking about an employee's disability like that, and then my friend interjected that my health is also a benefit to the organization because it's part of why I am good at what I do. I've always thought that was true, too.

So Ellen and I talked about all of this, and we both felt pretty good about it. Not celebrating WOOHOO kind of good, but just content, comfortable, peaceful kind of good. After ruminating on all of this, Ellen asked me if I wanted to check in. I knew that meant closing my eyes to see how the "gang" was feeling about all of this.

The little girl and the teenager were sitting up against a tree relaxing, happy. The blueberry jam girl was still eating, but more slowly.

"How do they feel about all of this? I mean, not what do they think, but what's in their hearts?"

"We all have the same heart," I said. And then it dawned on me.

"It's my heart that makes me special. It's not that I'm smart. It's my heart."


"It's not the fact that I'm sick that makes me good at this work. It's my heart that makes me good at this."


And the blueberry jam girl stopped eating for a minute, listening. And my spirit guide smiled its wise smile. And I knew I had unlocked another door to my self. Jennifer

The Rich Get Richer

The LA Times reports that several consumer groups are pressing for an investigation of health insurers' spending on medical care, claiming that medical-related expenses have decreased while premiums have increased. The new health reform law, starting next year, insurers have to spend 80-85% of premium dollars on health care. These consumer groups argue that the insurance companies are taking one last shot at reaping profits before that part of the law kicks in. Jennifer

Unhide the Ball

More good news: consumer protections will be beefed up so insurers -- including disability insurers -- can't hide the ball on you. This is a really important step to take. Wonderful. Jennifer

Two stories

Two interesting stories in this morning's Kaiser Health News.

First, a piece reminding us how hard it is to be poor and sick in America.

Second, a piece on a consumer scam that's proliferating -- limited benefit health plans. Beware.


Prescription: Produce

Some doctors in Massachusetts are giving out coupons to buy local produce as one step towards addressing the obesity epidemic in America.

As you know, I can't eat most fresh fruits and veggies due to Crohn's disease and gastroparesis, but yesterday, I took a ride out into rural Connecticut and brought home a container of locally grown cherry tomatoes. I don't know how much eating cooked veggies with some cherry tomatoes and olives thrown in is doing for my weight -- not enough -- but YUM! Jennifer

Model Research

This article chronicles the cooperative spirit among doctors seeking keys to Alzheimer's. By sharing data, they found answers that may help many people prevent and treat Alzheimer's in the future.

Shouldn't this become a model for medical research? Jennifer

Quality of Foreign Doctors

I've heard it a thousand times. A patient complaining that the doctors they saw in the hospital were foreign-born and trained. Well, here's Pauline Chen's piece explaining that foreign doctors are every bit as good as Americans. Jennifer

Thursday, August 12, 2010

Why I love my job

I got a call a few weeks ago from a nurse at a children's hospital. John, who is 3 1/2 years old, needs a special pulmonary vest or he will die. It costs $16,000 and insurance won't cover it. I wrote to the President of Hill-Rom, which manufactures the vest, and asked if they would donate one. Today I heard: YES!

See? There are really amazing people out there. They may not realize they're amazing. They may just need an opportunity presented to them, a chance to do something really special. And the people with good in their heart take that opportunity when it comes along.

How many lawyers get to save a baby's life? I am so honored. Jennifer


Apparently, many Americans still believe that the health reform law will create death panels making end of life decisions, slash Medicare benefits, and harm them in other ways, according to USA Today. I guess we still have a lot of work to do to educate the public about what the law really says. You can't very well expect all Americans to read 3000 pages of legislation, and I suppose it must be difficult for consumers who don't know me or Families USA or the Kaiser Family Foundation or the other groups trying to do public education to decide who to trust. I wish I knew how to make this all less scary for folks. I guess I'll just keep on talking and writing and talking and writing, and hope that everybody else who's studied the legislation will do the same. Jennifer

Waiting in the Wings

For those who oppose health care reform, would you prefer that we dismantle Social Security and Medicare? If not, read this and think twice about who you support and why. Jennifer

Wednesday, August 11, 2010

Gee, what a shock -- NOT!!!

A study finds that there's a communication gap between doctors and patients. I think we all -- including a lot of doctors -- know that. The question is what to do about it. Jennifer

Same Stuff, Different Day

It seems that insurance executives haven't quite had their fill of huge paydays on the backs of consumers, who are watching their premiums rise in the double digits. If the insurance companies didn't/don't want health reform, they could have stopped taking such huge compensation packages at a time when premiums were increasing to this extent. I don't know about you, but I can't help thinking that my $1165 per month -- yup, that's our monthly premium per person -- is helping to fund someone's McMansion rather than funding my health care. Jennifer

It's Bipartisan!

Here's a really interesting opinion piece demonstrating that there is bipartisan support for at least some of health reform. Jennifer

Staph Infections Dropping

Nice to read about a decrease in hospital acquired infections for a change. Jennifer

Celebrating Caregivers

All too often, caregivers are taken for granted -- the spouse, the adult child, the neighbor, the friend. Here's a nice reminder of the goodness it takes to allow people to grow old in their own homes, flourishing. Jennifer

Tuesday, August 10, 2010

Comments on Regulations on Pre-Existing Condition Insurance Plans

August 10, 2010


Centers for Medicare & Medicaid Services
Department of Health and Human Services
Room 445-G
Hubert H. Humphrey Building
200 Independence Avenue, SW
Washington, CT 20201


Dear Sir/Madam:

Thank you for this opportunity to comment on the interim final rules pertaining to the Pre-Existing Condition Insurance Plan (PCIP) Program. Advocacy for Patients with Chronic Illness, Inc. is a 501(c)(3) nonprofit that provides free information, advice and advocacy services to patients nationwide in areas including health insurance. Of particular relevance here, we receive hundreds of requests for assistance every year from people who are uninsured and cannot find health insurance due to a pre-existing condition. It is from this unique perspective
that we submit the following comments.

We are very gratified by the creation of the PCIP program as a temporary measure to accommodate consumers with pre-existing conditions until pre-existing condition exclusions are eliminated in 2014. In some States, high risk pools have been an important option for consumers. However, existing State high risk pools have several defects which the PCIP program should avoid:

• First, they are too expensive for most people.

• Second, they often cover people with a narrow range of listed conditions.

• Third, they have pre-existing condition waiting periods as long as twelve (12) months.

• Fourth, they have annual and lifetime caps that greatly limit the value of this insurance of last resort.

• Fifth, they cap enrollment so as to fail to fulfill the promise of providing a real option for people with pre-existing conditions.

Although the PCIP program avoids some of these pitfalls, it does not avoid them all. Below we offer specific suggestions to amend the regulations to address these hazards.


Although the interim final rules set forth four alternative means by which a consumer may establish that he/she has a pre-existing condition, the federal PCIP program will only allow proof of a pre-existing condition based on written proof that the consumer was denied coverage under another insurer due to the consumer’s health, or only with an exclusory rider. 75 Fed. Reg. 45017. This is so even though the Agency “note[s] that in some cases, individuals with pre-existing conditions are unable to obtain outright written coverage denials, but instead are told that carriers will not accept their applications.” Id. This is quite unfair. If insurers will not accept an application from a person with a pre-existing condition, which many do, then it may be impossible for the consumer to obtain the proof that you require. We already have heard of consumers facing this obstacle. Thus, we would urge the Department to consider allowing consumers to prove that they have a pre-existing condition by other means, such as a medical certification from a treating physician establishing that the consumer has a pre-existing condition, or an attestation from the consumer stating that they were denied coverage due to their pre-existing condition.

Second, the PCIP program is permitting states to condition eligibility on evidence that a consumer has a medical or health condition specified by the State. 45 C.F.R. § 152.14(c)(3). These State lists often are old, they do not even attempt to include the full array of rare diseases, they exclude many pre-existing conditions that prevent the purchase of commercial health insurance, and, thus, they bear no rational relation to the purposes of the PCIP program, or the State high risk pool, for that matter. They differ in different States, so there is no uniformity of consistency.

If the Department is going to take the position that the PCIP program is a federal program regardless of whether it is administered by a State, and that uniformity is a desirable goal as embodied in the interim final rules on appeals, then there should be federal standards for eligibility. At the very least, a State using a list of approved illnesses should be required to submit that list to HHS for review, and there should be some mechanism for consumers to petition to have additional illnesses added to this list. However, again, we would suggest, as an alternative, that the submission of medical certification that the consumer has a pre-existing condition, regardless of whether the condition is on a State’s list, should be a sufficient basis on which to establish eligibility.


Congress intended that the PCIP program bridge the gap between the passage of the Act and January 1, 2014, when pre-existing condition exclusions are eliminated for all Americans. Congress used the best estimate it had for the cost of the plan. For the Department to allow States to “manage enrollment over the course of the program” even before there is any evidence that the funds allocated to the PCIP program are insufficient deals a blow to Congressional intent. The Department is suggesting mechanisms like enrollment caps, phrased in or delayed enrollment, and “other measures.” 45 C.F.R. § 152.15. This appears to grant PCIPs permission to utilize these measures to “manage enrollment” without first requiring that the PCIP’s funds are insufficient to cover benefits for the consumers enrolled in the PCIP, seemingly without restraint or limitation, although 45 C.F.R. § 152.35 does require a showing of insufficiency of funds before a PCIP can make “adjustments.” We strongly object to this wholesale grant of power to limit the reach of a PCIP to the PCIPs (i.e., to the States) without even the preliminary showing of insufficiency of funds set forth in 45 C.F.R. §152.35. We urge the Department to clarify the rules to require a showing of insufficiency of funds before a PCIP is allowed to impose caps on benefits or enrollment, or other measures designed to control costs.


We very much support the prohibitions on pre-existing condition exclusions and waiting periods set forth in 45 C.F.R. § 152.20, as well as the premium and costsharing principles set forth in 45 C.F.R. § 152.21. However, because the out-of pocket limits set forth in the rules apply only to in-network benefits, 75 Fed. Reg. 45019, States are setting exorbitant out-of-pocket limits for out-of-network benefits without regard to the adequacy of the PCIP’s network. For example, Connecticut’s out-of-pocket maximum for out-of-network benefits is $15,000 for an individual and $30,000 for a family. However, Connecticut’s PCIP is piggy-backing on the State’s Charter Oak Plan, which has had such an inadequate network that consumers have demanded that their premiums be returned, albeit to no avail.

In addition, the lists of covered benefits and excluded benefits set forth in § 152.19 beg more questions than they resolve.

• May a PCIP utilize annual caps on benefits? Lifetime caps? It is our understanding that the State of Connecticut, for example, believes it has approval for a $1.5 million lifetime cap on PCIP benefits. Is this so? We strongly urge the Department to restrict the use of lifetime and annual caps on benefits.

• May a PCIP place an annual cap on particular benefits; for example, may it limit pharmacy benefits to $7,500.00 per year, or physical therapy to twenty (20) visits per year? For example, Connecticut’s PCIP has a $2,000.00 annual cap on outpatient mental health benefits – something that violates the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 and the implementing regulations even if it does not violate the Affordable Care Act and the interim final rules. Is this acceptable to the Department? Again, we strongly urge the Department to limit caps on particular benefits, and to clarify that the MHPAEA applies to the PCIPs.

• Who decides whether a service is medically necessary? Experimental or investigational? Based on what standards? At the very least, there should be a cross-reference to the interim final rules governing appeals, the NAIC Model Act, or both.

• What prescription drugs are covered for what uses? Although the rules permit PCIPs to have networks, may they also use formularies or preferred drug lists? May they utilize tiers, which place the cost of the newest and most expensive prescription drugs beyond the reach of many consumers? The federal PCIP charges $300 per month for nonformulary brand name specialty medications. Which medications are considered specialty medications? At the very least, consumers should be aware of these limits before they enroll in a PCIP.

Although the exclusion of abortion services – even if such services are paid for entirely by private premium dollars, but through a PCIP – has received the most attention, these and many other questions remain, and these are tremendously important questions to consumers. We have had significant experience with State high risk pools. Many of them leave much to be desired in many respects. We would like to see greater Departmental supervision in the area of benefit design. There is a lot of middle ground between giving the States free reign and needlessly tying their hands. In our view, the balance that has been struck by the rules as they read currently leaves far too much discretion to the PCIPs (and, thus, the States). The only way the Department can ensure that federal dollars are being spent consistently with federal intent is to exercise more control over, and provide more guidance to, the PCIPs.

Finally, we strongly urge the Department to clarify the prescription drug benefit in the federal PCIP. People with pre-existing conditions – many of which have multiple chronic conditions – cannot afford these copays and coinsurances unless they are applied against the annual out-of-pocket limit. However, the description of benefits posted on http://www.healthcare.gov does not state whether the high prescription drug costs are applied against that limit. If they are not, they
must be; patients with multiple sclerosis, Crohn’s disease, rheumatoid arthritis, psoriatic arthritis, many forms of cancer, and other illnesses for which specialty drugs routinely are prescribed cannot afford the PCIP’s copays and coinsurances if they are not included in the out-of-pocket maximum, so that once they reach that maximum, drug coverage is at 100%.


Finally, we are concerned that the appeal provisions, as well, are not sufficiently detailed to constrain the PCIPs from infringing on consumers’ rights. While we very much appreciate the intent to have at least one level of appeal and at least one independent review, we strongly urge the Department to be a little more specific. In particular, we are very concerned that “an entity independent of the PCIP” may be construed to include a State agency, so that one State agency could be operating the PCIP, while another would be deciding reconsiderations of a
redetermination. 45 C.F.R. § 152.26. This is not, in our view, true independence. Reconsiderations of redeterminations should be presided over by truly independent reviewers, i.e., not state agencies or employees. It is critical that the rules clarify the meaning and scope of independence.


We are very pleased that, now, when we receive telephone calls from consumers who have pre-existing conditions and can afford insurance – especially in States that have no high risk pool or guaranteed issue option – we have a resource for them. Our goal, through these comments, is to assist the Department to ensure that the PCIP program is as good a resource as it can be under all of the circumstances. We hope that the Department will elaborate on these rules so as to ensure that this goal is met.

Jennifer C. Jaff
Executive Director

The Boomers Are Coming

Interesting WashPo piece talking about how the health care system will support and accommodate the boomers -- that means YOU (and me). We are set to age in numbers that far surpass our parents' generation. Can society keep its promises? Jennifer

Hard Sell

According to Politico, despite receiving rebate checks to close the doughnut hole, and despite AARP's strong support for health reform, seniors remain skeptical. We still have a lot of educating to do -- and not just of seniors. Jennifer

Who Goes to the ER?

It turns out that 20 percent of Americans do, insured or not! What does this mean for our common belief that people without insurance use ERs for health care? Jennifer

Sunday, August 8, 2010

A Cool Idea for Memory Loss Patients

Check this out. An innovative, perhaps fun idea for patients suffering from memory loss. Jennifer

Saturday, August 7, 2010

ER Blues?

Here's some really good advice about how to deal with that bill for the emergency room visit. Jennifer

Friday, August 6, 2010

The Effect of Politics

If politics drives health insurance premium ratesetting decisions by states, as stated in this article, then the answer is that voters have to speak their piece to their elected officials at the state level if the balance of power is going to shift to consumers. Jennifer


To pay for aid to the states for Medicaid and child nutrition, the Senate would drastically cut the Food Stamp program. Does this make any sense to anybody? It sure seems counter-intuitive to me. Read here. Jennifer

Child Nutrition Funding

The Senate has passed a bill that would provide funding for child nutrition, including funding for the school lunch program, which hasn't seen an increase in 30 years. Read about it here and here. Jennifer

Thursday, August 5, 2010

Health Reform Strengthens Medicare

The Medicare Trustees released their annual report on the health of Medicare today. It says that the Medicare trust fund will be extended to 2029 -- 12 years longer than they projected only one year ago -- and they attribute this strength to health reform. So much for the notion that health reform will weaken Medicare. J

Ms. Justice Kagan

BREAKING NEWS: Elena Kagan was just confirmed as the fourth woman to sit on the Supreme Court. This marks the first time three of the nine Justices were women. Justice Kagan's tenure will be immensely important for many reasons, including the likelihood that she will hear the challenges to the health reform legislation. Jennifer

The More You Know The More You Like

The more voters know about health reform, the more they approve of it, says Harry Reid. The Kaiser poll last week (see post below) showed that in real numbers.

And so we must continue to educate and engage, no matter how tough the fight. Jennifer

Mental Health Parity or Stigma

As the new mental health parity regulations take effect, there is this report about stigma attached to seeking mental health services in the State Department. Parity means little if people who seek mental health services still have to fear for their jobs. We have to come around on this. People with mental illnesses are no different than people with physical illnesses. They need care and understanding. Jennifer

Obesity Rates on the Rise

Obesity is a major public health challenge in America. A new report says it is on the rise, despite all the talk about it and even the First Lady's efforts.

I'm swimming every day, eating fruits and veggies, doing my best to try to eat healthier. It's not enough, but it's better than nothing. What are you doing? Jennifer

Aid to States Finally Passes

Yesterday, the Senate cleared the way for aid to states for Medicaid funding and teachers' salaries. But no COBRA subsidy. Jennifer

Wednesday, August 4, 2010

Missouri Votes No

No surprise. The voters of Missouri -- actually, mostly voters who came to the polls for Republican primaries -- have voted against the provision of the new health reform law that mandates that people buy insurance. This has little, if any, meaning since the law is federal, although if this were held to be a valid position for states, the whole law would tumble. Still, I think the battle over this law will be in the courts, not in the ballot boxes.

But I am frustrated. How do we educate people about all the good this law is already doing, and will continue to do in the years to come? I absolutely believe that if people understood it, they would be for it. Jennifer

Tuesday, August 3, 2010

Health Reform Provisions that Take Effect Next Month

Here's a good catalogue of the health reform provisions that take effect at the 6 month anniversary of the signing of the health reform bill -- September 23, 2010. I've been blogging about lots of them, and posting my comments on the federal rules, too. But if you have any questions, feel free to post a comment and I'll do my best to answer.

It's getting exciting! Jennifer


How much does it matter whether your doctor actually touches you or not? This nice essay says it matters - not only to the patient, but also to the doctor. I agree. Jennifer

Don't Cry for the Insurance Industry

Humana reports a 21% increase in net profits in the second quarter. So health reform surely isn't hurting the industry. Jennifer

New Law Will Save Billions

According to a report released yesterday, Medicare will save $8 billion over the next year due to reform, and consumers will save, as well. I realize there is skepticism about this; how can everybody save money without reducing benefits. The answer: by reducing fraud and waste.

When I worked for the Attorney General's Office here in Connecticut, I focused on Medicaid fraud. It was astounding to see the millions of dollars being thrown away by duplicate payments, all kinds of administrative waste, and outright fraud. My experience tells me the same must be true in Medicare. So if the government goes at it right, I believe we will all see huge savings. Jennifer

Litigation Moves On

A court in Virginia declined to dismiss the State's lawsuit against health reform. So the woman I spoke with yesterday afternoon, who's losing her insurance at the end of the month, can't afford any alternative, and has to try to scrounge for free meds so she doesn't end up in a wheelchair -- I guess spending tax dollars to attack the law rather than helping people like her doesn't make any sense to the powers that be. Ugh.

And by the way, look back a few posts to learn more about the judge who made this ruling. Jennifer


Here's a reminder of how much work it's going to take to transition well. I know I think about this when I draft comments on the regulations. I know compromise is necessary. I also know there will be strong comments coming from industry. So I pick the important issues and argue strongly for them. I wonder how this will all look in 2015!

And here's another article about the changes that will have to be implemented before reform is fully up and running. Jennifer

Monday, August 2, 2010

Jonathan Cohn: Repealers are Wrong

Jonathan Cohn -- one of the best writers on health care in America -- explains why the repealers are wrong. Let's hope they read it. Jennifer

Weight Part 6.5

Shrink on vacation this week, but that doesn't mean I have the week off. I WENT SWIMMING THIS MORNING!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! It was amazing. I promised myself 10 days ago -- in therapy, I committed to the Blueberry Jam girl that I would start swimming today. Consciously, I kept saying no, I'm too tired, I can't get up that early, I'll start some other time. But when I got up today, it was almost like automatic pilot, and before I knew it, there I was, in the water. Swimming. Back and forth with my waterproof iPOD blasting tunes that motivate me. I feel downright heroic. I did this for ME! WOOHOO!!! I'm SO proud of myself. I did it! The first day is the hardest, and I know I will keep at it. I just had to start. And now I have. YAY ME!!! Jennifer

Republicans to Deny Funding for Health Reform

If they don't have the votes to repeal, now they will instead vote to deny funding, says Politico. Just when it's starting to get exciting, as new aspects of the law take effect in September -- things like expanded appeal rights, for example -- we have to worry that it will all be gutted.

I'm tired of the negativity in politics -- period. Aren't you? Jennifer

Missouri to Vote No -- Then What?

Will Missouri opt out of the health reform law? The NY Times says yes. But what if they do? There's a little thing called the Constitution that says federal law trumps state law. And even more, do you want to pay for health care for people who opt out, don't insure, and end up in emergency rooms? Chaos and more tax dollars spent on law suits -- that's what I see in the future. Jennifer