Florida Judge -- As Anticipated -- Rules Against Health Reform

Judge Roger Vinson today ruled that the health reform law is unconstitutional. His ruling will be appealed to the US Court of Appeals for the 11th Circuit. This is the second court to rule the law unconstitutional; the other court is in Virginia, and the US Court of Appeals for the 4th Circuit will hear that appeal in May.

Judge Vinson did not order the Obama Administration to stop implementing the law in the meantime, so all goes ahead as planned.

The judge said that the requirement that everybody purchase insurance or pay a fine/tax is unconstitutional, and since the law does not say that any one provision can be severed and the rest of the law still stand, he said the entire law is void.

Four judges now have ruled on the merits of the law, two for and two against.

I'll be reading the whole decision and will be able to give you a better idea of how this may play out after I've done so. Jennifer

Advocates' Letter on Appeal Regulations

January 31, 2011

Phyllis Borzi
Borzi.phyllis@dol.gov

Karen Pollitz
Karen.Pollitz@hhs.gov

Dear Ms. Borzi and Ms. Pollitz:

We, the undersigned consumer advocacy organizations, write to provide you with our viewpoint regarding several aspects of the new appeal procedures under the Affordable Care Act: external appeals in self-funded plans; the content of notices; language access; urgent care claims; and “substantial” versus “strict” compliance with the rules.

I. External Appeals in Self-Funded Plans

First, we urge the Department of Labor to stand firm for consumers in rejecting the position that the Secretary should “deem” existing second-level internal appeals offered by some self-funded plans as sufficient to meet the Affordable Care Act’s mandate that all consumers have the opportunity for an external review process that “at a minimum, includes the consumer protections in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners . . . .” ACA § 2719.

In our experience, there are many self-funded plans that do contract with physicians or organizations that employ physicians who review plans’ coverage decisions. However, this is not an external review as established by the NAIC Model Act. A true external review, which exists in many States, operates independently of the insurer or plan. The consumer sends the request for external review to a State agency; the State agency chooses an independent review organization (IRO) at random out of several possible IROs; the IRO conducts the review, taking both the consumer’s and the insurer’s or plan’s position into account; and the IRO decision is then sent to both the consumer and the insurer or plan, and is binding on the insurer or plan. A process that departs from these basic constructs cannot provide the independence necessary for the external review to serve as a genuine check on the insurer or plan’s policies and practices.

Independence is absolutely essential to a functional external review. We know, for example, that when insurers or plans act as the hub, receiving the appeal, choosing the outside reviewer, receiving the decision of the outside reviewer, and then issuing a decision to the consumer, outcomes are skewed in favor of insurers or plans. For example, an investigation in Illinois found that insurers were calling so-called IROs and complaining about particular medical reviewers, asking that those physicians no longer review the insurer’s claims, thereby directly and unduly influencing outcomes. We also can cite cases in which an IRO ruled in favor of consumers in true external appeals administered by States, but the same so-called IRO ruling on the same treatment for the same condition ruled for the plan when the outside reviewer was selected by the plan. Outside reviewers who become “captive” to the plan rule in favor of the plan. The final rules must guard against this; and the Secretary should not “deem” a process lacking in independence to be sufficient under the ACA.

Not only are outcomes affected by a lack of independence, but the quality of the outside reviewer’s analysis also is affected by how closely its interests are aligned with those of the insurer or plan. Most insurers and third-party administrators have clinical policy bulletins, some of which are deeply flawed, representing quoted abstracts that may be inaccurate and/or out of date. “Captive” outside reviewers may not go further than to rubber stamp the application of the clinical policy bulletin to the facts of the particular case.

However, a truly independent external reviewer would do his or her own literature search and analysis, and would issue a decision that reviewed the consumer’s medical history and analyzed the medical literature with an entirely fresh – and competent – pair of eyes.

Further, in order to achieve true independence, external reviews must be de novo, and no deference should be shown to the plan administrator, as is set forth in the NAIC Model Act. An external reviewer should view the file anew, with fresh eyes and an unbiased viewpoint. The question is not whether there is any rationale pursuant to which the plan’s decision can be upheld; it is whether the plan’s decision is correct. Paying deference to what may well be an erroneous decision would only repeat the plan’s error, if in fact one has been made. De novo review provides the best opportunity for accurate, unbiased outcomes.

The second-level internal appeals that self-funded plans wish the Secretary to deem sufficient lack not only true independence, but also transparency. Consumers have no way of knowing how the reviewer was chosen, who the reviewer was, or even what the reviewer actually said. In most cases involving self-funded plans, the decision is reported by the third party administrator or the plan itself. It references and reports the reviewer’s decision, but a copy of that decision is not provided to the consumer. Appeals that consist of hundreds of pages of medical records and medical journal articles may be denied in a paragraph or two, and since these often are the final word because many consumers cannot proceed to court for a whole host of reasons, the consumer is left wondering whether their appeal even was read.

In short, we believe that both independence and transparency are essential. If plans are going to be allowed to administer their own “external review” process, they should be required to contract with more than one IRO; they should be precluded from discussing the case with the IRO except in writing; a copy of any written communication should be provided to the consumer, with an opportunity to respond; and the IRO’s decision in full should be provided to the consumer. The plan should not be allowed to frame questions such as: “Please review this case to determine if [the plan] applied its Medical Policy correctly,” since that entirely avoids the question of whether the Medical Policy is itself correct. The IRO should review the insurer’s or plan’s file and the consumer’s appeal, do its own research when appropriate, and issue a thorough decision that allows both parties to feel confident that the review was performed independently and conscientiously. This is the intent behind the plain language of the ACA; and this is the bare minimum that is necessary to ensure that external reviews are meaningful.

Finally, we cannot overstress the importance of the IRO’s decision being binding on the insurer or plan. All of the independence and transparency gets us nowhere if a plan can simply veto the external reviewer. Allowing a plan to overrule an external reviewer not only is inconsistent with the Congressional language that refers to the NAIC Model Rule, but it also vitiates the protections that external review provides, frustrating clear Congressional intent. The external reviewer’s word must be final and binding.

II. Content of Notices

Second, we understand that there are concerns about whether confidentiality is breached by including a significant amount of personal medical information in EOBs and denial letters. However, we also know that consumers need access to enough information to afford them a meaningful opportunity to appeal. These interests should be balanced in a way that maintains confidentiality in the event the EOB were to be opened by anyone other than the patient, while at the same time ensures that consumers – many of whom never have had to appeal an insurer’s decision before – know what information to ask for if all of the necessary information is not included in the EOB or denial letter. In addition, although this should go without saying, the Departments should enforce consumers’ interest so that insurers and plans cannot construe this request for information as the initiation of the appeal itself. This erroneous and violative practice has been pervasive, and is very difficult for consumers to reverse when it occurs.

III. Language Access

With respect to translation of written communications into other languages, our sense is that insurers and plans that are balking at this are, at least to some extent, exaggerating the burdensomeness of this requirement. They would prefer to interpret orally rather than provide written notices translated into an enrollee’s language. Oral interpreting seems to us to be far more expensive since expenses for interpreters would be incurred for each individual needing assistance. Having a set of templates prepared in each language that meets the regulation’s thresholds, with only the patient-specific information having to be translated on an individualized basis, is likely more cost-effective. In addition, quality control is far easier when communications are in writing. The “paper-trail” is also critical to ensure appropriate notice. If oral communication is allowed, will a plan meet the requirement by leaving a message on an enrollee’s answering machine? If the plan is unable to reach the enrollee within the time frames, are the timeframes waived and how does this impact the enrollee’s rights? And what if an enrollee does not have a telephone or shares a telephone with multiple individuals with whom the enrollee would not want health information shared?

Insurers and plans also complain that they do not know how to identify which insureds need translation into which languages. It would be simple enough to simply ask on enrollment forms whether translation of written communications is necessary, and in which languages. Most Medicaid and CHIP applications already do this and many have provided comments that the common application for the Exchanges should also collect this language. Further, most small businesses know if they have non-English speaking employees, and the native language of those employees, and they can furnish that information to the insurer or TPA.

While we agree that including “taglines” on notices in multiple languages is helpful when insurers and plans do not have language specific information, this places a burden on insureds to affirmatively call the insurer/plan to get additional information. Taglines should not be a compromise or option for plans but rather supplement the requirements to provide translated notices to ensure that insureds whose language needs are not noted are also informed of their rights.

Ensuring that people have the information they need means ensuring that they have access to that information in a form that they can comprehend. We simply do not agree that this requirement is unduly burdensome. Further, insurers or plans that operate in California are already subject to similar requirements under state law. And any plan or insurer that participates in Medicaid, CHIP or Medicare should be translating notices for frequently encountered languages pursuant to Title VI of the Civil Rights Act of 1964 (see the HHS “LEP Guidance” at www.lep.gov). Weighed against the benefits of providing accessible information, the scale clearly tips in favor of translation.

IV. Urgent Care Claims

Next, it is our understanding that insurers and plans are opposed to a 24-hour deadline for deciding urgent care claims, preferring, instead, a 72-hour window. The preamble to the interim final rules explains the Departments believe that electronic communication has evolved to the extent that information can be conveyed, and decisions can be made, far more quickly than they could in 2000, when the original DOL regulation providing the 72-hour window was promulgated. There is an exception to the 24-hour requirement when the claimant has not provided all of the necessary information to the insurer or plan.

These claims are, by definition, “claim[s] for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or, in the opinion of a physician with knowledge of the claimant's medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.” 29 C.F.R. § 2560.503-1(m)(1). Thus, they should be relatively rare, and in every case, time genuinely is of the essence.

V. Substantial Versus Strict Compliance

Finally, the interim final rules provide that, when an insurer or plan fails to “strictly” adhere to the requirements of the internal claim and appeal process, the consumer is deemed to have exhausted the internal appeal process and can pursue external review, regardless of whether the insurer or plan substantially complied with the regulatory requirements or whether any error is de minimis. Insurers and plans would prefer a “substantial” compliance standard to a “strict” compliance standard.

This is not an overly punitive provision. The claim or appeal is not deemed approved; the deeming affects only the ability to pursue remedies outside of the plan. In light of the delays suffered by consumers, this standard is entirely appropriate. Time and time again, insurers and plans lose, delay and even ignore internal appeals. If the consumer is represented by a third party and the third party submits a HIPAA release and authorization on its own letterhead rather than on a form buried on the insurer’s website, insurers may either ignore the appeal entirely or fail and refuse to communicate with the consumer’s representative. Over and over, appeals are lost or mistaken for a provider’s appeal, so no notice of denial is sent to the consumer, and the opportunity to file a second-level or external appeal is greatly delayed. Consumers who failed to appreciate the likelihood that they would have to prove that they filed an appeal and, thus, did not send the appeal with a tracking mechanism (certified mail, delivery
confirmation, etc.) have no recourse in the face of an insurer’s assertion that it never received the consumer’s appeal. At times, the insurer or plan fails to provide an address – or a correct address – to which to send an appeal, requiring that it be sent over and over again until it finally is received. Indeed, these sorts of unjustifiable delays are one of the most vexing issues in filing insurance appeals. And insurers and plans alone have the ability to remedy these delays. Strict compliance is entirely within the insurer’s or plan’s control.

The “substantial” compliance standard involves great ambiguity and subjectivity as to what is “substantial.” Indeed, courts do not even agree on whether the question of whether a plan has substantially complied is a question or law or of fact. Compare Ponsetti v. GE Pension Plan, 614 F.3d 684 (7th Cir. 2010)(question of fact) with Baptist Memorial Hospital – DeSoto, Inc. v. Crain Automotive, Inc., 392 Fed. Appx. 288 (5th Cir. 2010) (question of law). What constitutes substantial compliance is a question as to which the courts have not reached agreement; the courts articulate the standard slightly differently. See, e.g., Simonia v. Glendale Nissan/Infinity Disability Plan, 378 Fed. Appx. 725 (9th Cir. 2010) (substantial compliance exists in the absence of prejudice to the claimant); Estate of Thompson v. Sun Life Assur. Co. of Canada, 354 Fed. Appx. 183 (5th Cir. 2009) (substantial compliance exists if the violation was technical and the insured has a meaningful opportunity for review); Larson v. Old Dominion Freight Line, Inc., 277 Fed. Appx. 318 (4th Cir. 2008) (substantial compliance exists when plan administrator provides a sufficiently clear understanding of the administrator’s position so as to permit effective review). A strict compliance standard is far easier to enforce in that this same ambiguity and subjectivity is eliminated.

VI. Conclusion

We very much appreciate being involved in this ongoing dialogue to ensure that the ACA provides consumers with all of the protections that Congress intended. If you would like any additional discussion or information, please do not hesitate to contact us at patient_advocate@sbcglobal.net or cparcham@familiesusa.org.

Sincerely,

Elizabeth Abbott, NAIC Consumer Representative
Advocacy for Patients with Chronic Illness, Inc.
American Cancer Society Action Network
Brain Injury Association of America
Kim Calder, NAIC Consumer Representative
Center for Medicare Advocacy
Community Catalyst
Community Service Society of New York
Consumers for Affordable Health Care (ME)
Families USA
Health Care for All (MA)
Health Care for All New York
Health Access California
Timothy Stoltzfus Jost, Washington & Lee Univ. School of Law
National Health Law Program
National Partnership for Women and Families
National Women’s Law Center
State of Connecticut Office of the Healthcare Advocate
Tennessee Health Care Campaign
Universal Health Care Foundation of Connecticut
U.S. PIRG
Utah Health Policy Project
Vermont Office of Health Care Ombudsman
Virginia Poverty Law Center

Another Manic Monday

Monday already. Bummed. It's a slow news day, too. Here goes:

Democrats are making the strong case for health reform, highlighting the concrete ways the law is helping Americans.

Roughly 10,000 Americans are enrolled in the new health reform Pre-Existing Condition Insurance Plans. They're still too expensive for some folks in some states, and you have to have been without insurance for 6 months, but for some people who otherwise could not get insurance, these comprehensive plans are a great alternative.

Will health reform raise rates or lower them? It's more like the rate of increase will slow down, but not stop. Here's more.

States are considering cutting Medicaid, leaving more poor uninsured.

Who's really a doctor -- and who's not? Check it out if you're unsure.

In California, open enrollment for health insurance for kids under age 19.

The military fails to care for its brain injured troops when they get home.

Sing your baby a lullaby. It will improve his or her health.

Meditation changes the brain in good ways.

Facial exercises to reduce wrinkles.

And that's it, a quiet Monday morning. No doubt, the week will heat up! So hang on and hang in. Jennifer

President Obama At Familes USA

President Obama spoke at the annual Families USA conference in Washington, DC this morning. Reports are that he said, essentially, that he's willing to tweak the health reform law, but will not allow it to be repealed. He said he supports eliminating the 1099 requirement (a bookkeeping requirement that would impose a huge burden on small businesses), and to possible malpractice reform and patient safety innovations. But he stressed that seniors are benefiting from help with Medicare part D drug costs, and young people are on their parents' policies, and people can access preventive care. See also here.

He also said the new law is NOT budget busting, job killing, or granny threatening! The experience over the last 10 months shows that small businesses are offering health insurance, some for the first time. The Business Round-Table says that businesses will see savings from health reform over the next few years. And, he said, "granny is safe." In fact, Medicare is stronger than ever, he said.

He said he will not "take this law apart" without consideration for the lives that hang in the balance. But he's willing to try to make care better and more affordable, and he remains open to other ideas.

Video is here. Jennifer

Medicare by Voucher?

The House GOP is considering privatizing Medicare. This is not new; it's been raised before. But most Americans -- including Tea Partiers who would otherwise limit the size of government -- do not want any cuts in Medicare.

Do we need to cut entitlements to control the deficit? We know that Social Security, Medicare and Medicaid are the biggest chunks of the budget, along with defense spending. But are you ready to raise the retirement age? What about means testing for Social Security, so the wealthy don't get any?

The GOP tends to talk about privatization as a cost cutting measure, claiming that it doesn't reduce benefits. I'm skeptical of that claim, as are most Americans.

But as the federal government grapples with the deficit, watch for proposals like this one. Jennifer

Finally Friday Edition

President Obama appears today at the Families USA conference and will talk about health reform to an enthusiastic group of staunch supporters.

For those of us who can't be there, here's the news:

Dems say they are willing to tweak the health reform law, but how? They say they're open to malpractice reform, fixing the 1099 problem, but the GOP says they are not being concrete enough about what they are willing to do. Meanwhile, the 1099 fix now has 60 co-sponsors, which means it can pass the Senate.

HHS released a report saying that health insurance premiums will be 14-20% less in 2014 with health reform than they would have been without it. Rate increases are slowing, states are taking more responsibility for rate review, and the medical loss ratio rules (percentage of premium dollars spent on health care) will limit administrative expenses.

However, it's getting harder to find child-only health plans. Many insurers have stopped selling these policies because they now have to cover children with pre-existing conditions. However, some states have pushed back, and HHS says they are still talking to insurers about this.

Three insurers in California -- Anthem, Aetna and Pacificare -- have agreed to delay rate increases at the request of the new Insurance Commissioner. Blue Shield is the lone hold-out. The Commissioner had asked for time to review the rate increases and make sure they comply with the law. The Commissioner does not have the authority to reject the rate increases, so all he can do is ensure compliance with law.

Michelle Obama is lauding a health initiative by the US Army to improve health and nutrition.

And that's it today. A relatively quiet news morning. Enjoy! Jennifer

Dr. Chen Again

The marvelous Dr. Pauline Chen on Accountable Care Organizations and what they may mean for patients. As always, she's a must read. Jennifer

Thursday Themes

More snow. Unreal. But life must go on, so here's today's news:

The House GOP has begun holding hearings on health reform. The House Ways and Means Committee heard from business owners who testified that reform will hurt jobs. The Budget Committee heard from the Medicare chief actuary, who questions some of the Obama administration's financial assumptions and projections. Expect the House to keep this up pretty consistently for the next two years. And the Obama administration countered with business owners who say health reform is great for their business, for creating jobs, and with economists who argue that health reform will save money. What's an average Joe to make of all of this? Pretty hard to take sides in a battle of the experts. I'm going to keep looking at what reform is doing for the people who call me for help. For me, that's my best guide. Here's more on the Congressional hearings from Politico.

GOP Senators have introduced the repeal bill in anticipation of forcing a vote, probably by tacking it on as an amendment to some other law that the Democrats want. Meanwhile, Democrats have introduced a malpractice reform bill. And lawmakers are targeting the Medicare spending board for elimination. This is one of the major cost-cutting measures in the health reform law. Meanwhile, Democrats are moving to eliminate the 1099 reporting provision -- something everyone pretty much agrees needs to go.

And House Speaker and GOP leader John Boehner will be giving a keynote address to the annual conference of health insurance lobbyists. What's wrong with this picture?

Meanwhile, some conservative Democrats who initially opposed health reform are coming around to supporting it as their constituents urge them to oppose repeal.

The US Court of Appeals that covers Virginia has promised a quick ruling on health reform. Oral argument will be in May.

Center for Medicare and Medicaid Services chief Donald Berwick has been renominated by the White House. He took office under a recess appointment because the GOP refused to hold hearings on his nomination. Expect a full hearing in the Senate Finance Committee that may be more about health reform than it is about Dr. Berwick. Dr. Berwick is controversial; Republicans say he favors rationing health care -- a charge he has disputed.

Wellpoint -- which owns Anthem BCBS -- sees record profits once again. According to the Wall St. Journal, the profits are slightly down, but they exceed expectations. And why was it that they needed these premium increases?

Lawmakers in California are upset about what it costs to provide health care to prisoners. They're considering early release for prisoners with chronic illnesses. And here I never thought chronic illness would be a plus for some sufferers!

Meanwhile, the CDC says diabetes is on the rise. Considering what diabetes costs us all, this is bad news, but good incentive to continue to create wellness program and access to preventive care. Here's more.

In mental health news, two new studies. College freshman are suffering record stress levels. And abortion does NOT create a mental health threat.

And that's what I have for you today! Have a good one and stay warm and dry. Jennifer

Hartford Courant Webcast TODAY

Since you may be home due to snow today, how about curling up with your computer and joining in a webchat about what you need to know before you file an insurance claim from 12 to 1 pm today. Go here for more info. Jennifer

P.S. - Here's a link to the transcript in case you missed it.

I'm Going to the White House

Well, okay, the Executive Office Building next door to the White House. But still.

I've been invited to meet with Kareem Dale, President Obama's Special Advisor on Disability Policy to talk about the obstacles facing people with largely invisible chronic illnesses.

Exciting? Oh, yeah. Scary? Totally. But on Friday February 4, I will do my best to speak for all of us as I explain how hard it is for us to obtain the full protection of the law when people look at us and don't believe we're really all that sick.

I hope to represent all of us well. Jennifer

Wednesday Post-SOTU Edition

Well, the speech is in the can. Let's see what the pundits have to say about health reform this morning:

The President said that he knows there is opposition to health reform, and he's willing to negotiate changes, but he's not willing to go back to a time when insurance companies denied coverage due to pre-existing conditions. He's willing to repeal the 1099 bookkeeping provision -- everybody agrees this needs to go, so why it's not already gone I don't know -- and he's willing to consider things like malpractice reform. “So instead of re-fighting the battles of the last two years, let's fix what needs fixing and move forward.”

Still, the GOP response ties reform to the nation's debt. He says reform is driving up premiums -- something that I believe is factually unsupportable -- and that it threatens the health insurance coverage Americans already have -- although they didn't quite say how or why.

And a new poll says that Americans do not want the health reform law to be defunded -- 62 percent do not want the GOP to hold up funding to implement the changes. Still, Americans are divided on the law, although clear majorities are in favor of some of the law's consumer protections. Most Americans also support Medicare and Medicaid.

Still, Senator McConnell promises that there will be a repeal vote in the Senate.

Although the health reform law does give regulators the tools to review premium increases, if they are to have authority to stop those increases, the States will need to legislate accordingly.

Electronic health records -- long thought to be a key to improving care -- well, it turns out they may not improve care all that much.

Republicans want to let insurers sell policies across state lines. Why is that a problem? Because the State laws that guarantee minimum coverage of certain services would not apply, so people would buy cheaper policies that would cover a lot less.

And that's the health news this morning. Jennifer

Tuesday SOTU Edition

Tonight is the State of the Union (SOTU) address. I trust you all will watch and listen. Meanwhile, here's the morning news:

Will the President talk about health reform tonight? If so, he's likely to maintain a compromising tone, saying he's willing to work on improving the law, but he's not willing to take a step back and start from scratch.

The NY Times published an editorial today calling on the GOP to do more than say no to health reform, but to come up with something in its place that covers the uninsured and controls costs.

The Wall St. Journal says there will be a repeal vote in the Senate, although it's not likely to succeed.

And $4 billion have been recovered in health care fraud prosecutions -- one of the revenue generating items in health reform.

Meanwhile, the GOP continues its critique of the law. The 1099 reporting provision will go -- Dems agree with this one. But their other targets? The individual mandate; the independent payment advisory board (to help decide what things are not cost effective and should not be covered by Medicare, this board has existed for a long time, but just hasn't done much); flexible savings accounts (they want over-the-counter meds covered, and the end of the year balance rolled into the next year); and elimination of the CLASS Act, which would help people save for long-term care costs.

And there's already a bill that would change medical malpractice rules. There's nothing in health reform that contradicts this, so this can be passed without repealing anything.

But free preventive care is starting to show dividends in the form of a healthier public.

Is infertility treatment an essential benefit that should be required to be covered in health insurance plans?

The Department of Justice has sued Arkansas for keeping people with disabilities in a large institution rather than in group homes in the community. The institution, called Conway, houses about 500 people with both intellectual and physical disabilities -- and some of their families want them to stay right where they are. But studies show that people with disabilities fare better in the community.

Get this -- insurance companies are scouring social media sites like Facebook looking for evidence of fraud. If you're on disability, you probably shouldn't be posting about your ski vacation -- even if it was your first vacation in 20 years, and even if you sat in the ski lodge the whole time while your wife was on the slopes!

When is a doctor too old to remain in active practice? For some, sooner than they'd like.

Here's a really interesting piece, trying to talk to Navajo about end of life decisions when, in their culture, death is never discussed. Reminds us of the cultural and ethnic divides that affect our health care. Couple this with a study that says that 40% of terminal cancer patients never discuss end of life care with their physicians.

Trying to teach the "gut brain" how to know when it's really not hungry. Sounds great to me if they can figure out how to make it work.

And that's the morning's news. Today's all about the SOTU. Jennifer

Must Read

This is an incredibly wonderful, sad, happy, heartwarming story that you really MUST read. Keep tissues close, though. Jennifer

Check out my Guest Blog Post

On the Prepared Patient Forum -- and we all know the value of being a prepared patient! Jennifer

Monday Musings

It's all about the State of the Union tomorrow night. President Obama is expected to defend the health reform law in his speech.

And the abortion battle heating up yet again under the guise of attacks on health reform. Here's a smattering of what else is on the front burner:

The GOP vows a Senate vote on health reform repeal. Sen. Schumer says the Dems will make the GOP vote provision by provision, so they'll keep the Medicare drug cuts, letting kids stay on their parents' policies to age 26, etc., so it will look like "Swiss cheese." And the requirement that small businesses file 1099's on any goods or services over $600 will go -- everybody agrees it should. But full repeal in the Senate is not expected to win, even as a vote seems more likely.

The GOP replacement bill -- which hasn't been written yet -- is expected to focus more on decreasing costs than it does on covering the uninsured.

Meanwhile, health reform implementation proceeds, even in states that are part of a lawsuit to stop it in its tracks. And the House GOP plans to start hearings on health reform implementation, including the granting of temporary waivers to companies like McDonald's, that provide only limited benefit plans, as well as on malpractice reform.

A new federal research center will help develop drugs to get them to market faster.

Arizona has requested federal permission to tighten Medicaid rules and eliminate enrollees. Many states are complaining about the rule that States not drop anybody from Medicaid between now and when expanded enrollment starts in 2014, so Arizona has passed a law directing the Governor to formally request a waiver. So more poor people lose benefits? And this is good why?

A study finds that electronic health records and other high-tech health care delivery systems don't provide the benefits that people expected.

Here's a neat story about a "country doctor" who makes house calls via helicopter or horseback!

And that's the start on the day! Enjoy! Jennifer

The More Snow? Really? Edition

It's Friday, but the snow's getting old already -- third storm in 10 days. Oh, well. Might as well get down to the business at hand.

Get this. There's an email going around attacking reform that purports to be from a judge analyzing "Obamacare." It contains many inaccuracies, and actually refers to a version of the law that never passed!!! I've gotten questions about it; it's good to see the inaccuracies documented.

As was planned, the GOP in the House has charged 4 committees with the task of coming up with a Republican health reform proposal to replace the current law. In addition, a bill has been introduced to prevent federal funds from being used for abortion OR TO PAY ANY HEALTH PLAN that offers abortions -- so insurers can't offer abortion coverage even using private dollars if they want their plan in the Exchanges. Interestingly, although they just voted to repeal health reform, many Republicans are praising specific consumer protections contained in the law, such as allowing parents to keep their children on their policies to age 26 and providing help with drug costs to seniors.

In addition, the GOP has offered a bill to allow the sales of insurance across state lines. Why is this a problem? Because it would nullify all the state mandated coverages -- things your state says insurers have to cover, thereby taking away the right of states to regulate insurance. So is the GOP interested in states' rights or not?

Meanwhile, HuffPo reports that there is real concern that the GOP will shut down government over health reform by refusing to pass any appropriations bills that contain funding for health reform implementation.

And still, we proceed with implementation, with HHS announcing new grants to help States establish insurance Exchanges, the marketplaces where you will be able to see your insurance options and make informed choices.

This really isn't a surprise. A new poll finds that, although Americans prefer budget cutting to raising taxes to fix the deficit, they don't want to give up their full Medicare and Social Security. When it comes to those programs, Americans would rather pay higher payroll taxes. And they'd rather tax gasoline or impose a national sales tax than tax health insurance that they get from their employers.

And that's Friday morning's insights for you. Jennifer

Thusday's Themes

Did anybody notice that I thought it was Thursday yesterday? Too much snow, too tired.

But now it's really Thursday, and the House did vote to repeal health reform yesterday. Democrats defended the law by telling stories of Americans who've benefited.

So now we get down to business -- working to make the bill better, hopefully with some cooperation between the parties so we really get something done rather than just playing for politics. I'm trying to be optimistic; the GOP is now saying that it will keep those aspects of the law that it favors, like keeping children on their parents' policies to age 26. But they're still talking about choking off funding if they can't repeal, so it's still going to be a battle. And some GOP-ers seem to think pre-existing condition exclusions are no big deal, and they see the Democrats' support for reform as "irrational leftist lust for socialism." That kind of talk doesn't portend well for compromise.

Here's a breakdown of the vote. See what your Congressman did, and if he or she voted against repeal, thank him or her. Only three Democrats -- Dan Boren of Oklahoma, Mike McIntyre from North Carolina, and Mike Ross of Arkansas -- voted in favor of repeal, along with all of the Republicans.

Today, the House GOP will assign four committees to come up with proposals to replace reform. Expect to see proposals for malpractice reform, attempts to eliminate the individual mandate and replace it with . . . I don't know . . . and more. And even though the law is extremely clear that federal funds cannot be used for abortions, expect to see the GOP try to eliminate abortions under any insurance plan in the Exchanges, even if paid for entirely by the patient. I'll do my best to keep you up to date.

Meanwhile, the FDA is planning changes to its process for approving medical devices, streamlining the process for low-risk devices.

A survey of physicians finds pessimism about the future of health care. They are skeptical of health reform and believe it will make things worse for them. However, many of them signal that they don't know what the law says.

And that's it for this morning's news. Jennifer

House Votes to Repeal Health Reform

The House of Representatives has voted to repeal the health reform law. However, the Senate will not even take up the full repeal measure, and the White House would have vetoed it, making the repeal vote a symbolic one.

I also want to go on record as saying that the comments of Democrat Steve Cohen of Tennessee alleging that the GOP were acting like Nazis in attacking the health reform law is disgusting and should be resoundingly rejected by everyone, Democrat and Republican alike. There is no place for accusing elected officials who are doing what they see as their jobs of acting like the most reprehensible hate group the world has ever known.

As much as I am in favor of health reform, I am at least equally against this type of rhetoric. Jennifer

Ranks of the Uninsured Swells

From the Connecticut Mirror:

On the eve of the U.S. House vote on repeal of health care reform, Gallup reports that 16.4 percent of American adults were uninsured in 2010, up from 14.8 percent at the start of the recession in 2008.

During the same period, those getting insurance coverage through their employers declined from 49.2 percent to 45.8 percent, while those relying on government for coverage increased from 23.4 percent to 25.3 percent.

Groups most likely to be uninsured included Hispanics (38.9 percent), those earning less than $36,000 (29.7 percent) and young adults ages 18 to 26 (28 percent). That last group should benefit from the health care reform bill's provision that extends coverage of dependents until age 26, but for many plans the change did not take effect until late September.

Speaks for itself -- or it should, anyway. Jennifer

Wednesday's News - Health Reform Repeal Vote TODAY

If you have not yet called your member of Congress, please do. There are toll-free numbers you can use -- 888-876-6242.

The debate is well underway, and the House is divided but restrained. The parties disagree on the key issues -- the effect of reform on the federal budget, the effect on jobs, will it lower the cost of health care, and will it cover the uninsured. Those four questions form the battle lines. And plenty of myths abound. For example, experts say reform is not the "job killer" that the GOP claims.

Thankfully, the tone of the debate is more respectful than it's been, and polls are showing a shift in the American public, most of whom do not support a total repeal of the law. After all, as many as 129 million Americans have pre-existing conditions, and they would be far worse off if repeal won and there was nothing to replace it with. But truthfully, there are people who are enthusiastic supporters of the law, those who strongly oppose it, with the majority of Americans somewhere in the middle.

The House will vote this evening, and will vote to repeal -- the GOP has the votes, but only in the House. The Senate most likely will never vote on total repeal. This does not mark the end of the discussion, though. This is really the launch of what will be a two-year assault on the new law. Democrats know that they failed to explain the law well enough to the American people, so expect to learn more about the new law while the GOP chips away at it. The White House and Senate leadership continue to defend it. And others work to demonstrate how repeal would hurt business rather than helping it. Republicans say they will replace the reform law, but they haven't said with what. Democrats say they are willing to work with the GOP to improve the law. The White House has made the same offer. Even some prominent Republicans say that's the way to go. Still, the died hard GOP House leadership is intent on blocking implementation of the law.

In other ALARMING news, Politico reports that the rise in Social Security disability claims threatens to derail the program as it becomes more expensive than Social Security retirement. What a disaster this would be.

And yesterday, a number of advocacy organizations, including our friends at the Center for Medicare Advocacy, filed a lawsuit that seeks a ruling that patients with chronic illnesses are entitled to rehabilitative services even if their condition is not expected to improve. This is terribly important; Medicare often cuts off services to patients who need something like physical therapy to maintain their muscle tone, even though it won't cure their multiple sclerosis (for example). This lawsuit would put an end to that practice.

And that's today's news. Please call your member of Congress and tell them to vote no on repeal. Jennifer

Poll Shows GOP Opposition to Repeal Waning

According to a new poll, Republicans' desire for full-out repeal is beginning to lessen.

Great. So let's let that go and get on with the business of making the law even better! Jennifer

Frist Against Repeal

Former GOP Senator Bill Frist has come out against health reform repeal, saying his former colleagues ought, instead, to work towards improving the law that's on the books.

I don't recall the last time I agreed with Bill Frist. I guess there's a first for everything. Jennifer

Is Health Reform Good for Business?

Connecticut's Kevin Galvin says so. As he sifts through health insurance offers to cover his business, he believes the health reform law's tax credits for small businesses will allow him to hire more employees. Good news all around.

Are you sure you're in favor of repeal? Jennifer

Say NO to Repeal

Well, debate has started. Your members of Congress need to hear from you. Call the Capitol switchboard at

888-876-6242

or

877-264-4226

Or you can find your Senator's contact info here. Your member of the House of Representative here.

Don't assume your member of Congress is on board. They need to hear from you TODAY. So call. Thanks. Jennifer

More Snow? Edition

Yup, there's snow and sleet and all kinds of nasty stuff outside. So what's up with health news today? Here goes:

Today starts health reform repeal debate. Polls show opposition to the law is softening as it begins to take effect and people realize what's really in it. However, there's no clear plan to replace the bill, which means repeal would leave us back to where we were a year ago. As always, I strongly encourage you to check the facts before jumping to conclusions. Read about the myths and the facts about health reform. Learn. Think. Then decide.

What will happen is this. The House will debate today and vote this evening to repeal. Tomorrow, they will vote to assign committees to come up with alternatives. None of this will actually get passed in the Senate and signed by the President, although we're all open to tweaking the law and making it better.

Democrats, too, will be out there with their own message about the positive things the law has done already. Indeed, Dems will use the repeal debate to remind the American people of the benefits of the new law:

• No pre-existing condition exclusions for kids under 19;
• Kids up to 26 can stay on their parents' policies;
• There are pre-existing condition insurance plans for people who couldn't get insurance before due to pre-existing conditions;
• Preventive care is free;
• Insurers must spend 80 or 85 percent of premium dollars on health care, not on administrative costs;
• There are new appeal rules that let people get outside reviews of insurers' denials of coverage;
• Lifetime caps are eliminated and annual caps are being phased out;
• Insurers no longer can retroactively rescind your policy;
• And more.

Are you ready to give that up with no idea what you get in return? I didn't think so.

Well, expect this battle to go on over the next two years, as the GOP chips away at reform while more of the reform provisions take effect -- and you see how much you benefit from them.

In this context, consider the fact that half of all Americans under age 65 have pre-existing conditions. So if we're going to undo reform, what are we going to do to ensure that everybody who wants and needs insurance can get it at an affordable price? If the GOP has a good idea, I'd love to hear it.

Meanwhile, over 100 law professors have signed on to help support the constitutionality of healt reform. And a group of former members of Congress are launching a state-based reform effort.

In other news:

Mental health first aid courses -- in the wake of the Tucson shooting, attempts to teach people what to do if someone is becoming unhinged seems like a good idea.

Plan to have enough medicine with you when you travel or you may be caught short-handed with no recourse.

And that's this morning's news. I hope you aren't seeing outside your window what I'm seeing -- YUK! Jennifer

Health Reform Repeal Text

Just a reminder, since debate starts today. Here's the language of the repeal bill and the language of the replace bill, in that order.

The House of Representatives will debate today, and vote tomorrow, on repealing the health law. Here are the texts of that repeal bill and a Republican resolution "instructing certain committees to report legislation replacing" the law:

The 2011 GOP Health Law Repeal Bill

A BILL
To repeal the job-killing health care law and health care-related provisions in the Health Care and Education Reconciliation Act of 2010.

See H.R. 2

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ‘‘Repealing the Job-Killing Health Care Law Act’’.
January 3, 2011 (5:41 p.m.)

SEC. 2. REPEAL OF THE JOB-KILLING HEALTH CARE LAW AND HEALTH CARE-RELATED PROVISIONS IN THE HEALTH CARE AND EDUCATION RECONCILIATION ACT OF 2010.
(a) JOB-KILLING HEALTH CARE LAW.—Effective as of the enactment of Public Law 111–148, such Act is repealed, and the provisions of law amended or repealed by such Act are restored or revived as if such Act had not been enacted.
(b) HEALTH CARE-RELATED PROVISIONS IN THE HEALTH CARE AND EDUCATION RECONCILIATION ACT OF 12 2010.—Effective as of the enactment of the Health Care and Education Reconciliation Act of 2010 (Public Law 111–152), title I and subtitle B of title II of such Act are repealed, and the provisions of law amended or repealed by such title or subtitle, respectively, are restored or revived as if such title and subtitle had not been enacted.

House Resolution For 'Replacing' The Health Law

See H.Res. 9

RESOLUTION

Instructing certain committees to report legislation replacing the job-killing health care law.

Resolved, That the Committee on Education and the Workforce, the Committee on Energy and Commerce, the Committee on the Judiciary, and the Committee on Ways and Means, shall each report to the House legislation proposing changes to existing law within each committee’s jurisdiction with provisions that--

(1) foster economic growth and private sector job creation by eliminating job-killing policies and regulations;

(2) lower health care premiums through increased competition and choice;

(3) preserve a patient’s ability to keep his or her health plan if he or she likes it;

(4) provide people with pre-existing conditions access to affordable health coverage;

(5) reform the medical liability system to reduce unnecessary and wasteful health care spending;

(6) increase the number of insured Americans;

(7) protect the doctor-patient relationship;

(8) provide the States greater flexibility to administer Medicaid programs;

(9) expand incentives to encourage personal responsibility for health care coverage and costs;

(10) prohibit taxpayer funding of abortions and provide conscience protections for health care providers;

(11) eliminate duplicative government programs and wasteful spending; or,

(12) do not accelerate the insolvency of entitlement programs or increase the tax burden on Americans.

MLK Day Edition

"Off all the forms of inequality, injustice in health care is the most shocking and inhumane." Rev. Martin Luther King, Jr.

In that context, I begin by reminding that the health reform repeal vote is scheduled for this week. A new poll shows Americans are evenly split on reform. Expect to hear a lot of negatives, but also a lot of positives from Democrats who look forward to explaining all the good the new law is already doing. Expect the House GOP majority to vote for repeal -- but that will then die in the Senate as the GOP tries -- probably with some more success -- to repeal particular sections of the bill. For example, there are those in the GOP who want to help the insurance industry even more by eliminating the requirement that 80 or 85 percent of premium dollars are spent on health care -- one of the few cost-saving measures in the law. Expect this to go on for a good long time.

Meanwhile, implementation proceeds, with the next step being the identification of the essential benefits package - the things that all insurers who want to participate in the Exchanges will have to cover in their policies.

Does health reform affect jobs? Positively or negatively? The experts are split, it seems.

California Blue Shield refuses to delay rate hikes, as requested by the new Insurance Commissioner, who simply asked for time to get up to speed since he just took office.

Lots of talk about mental health reform in light of the Tucson shooting. Guiliani says the shooter was crying out for help. Why does it take a crisis for us to focus on mental health? We need to find ways to identify those in need sooner, say others.

When budget cuts mean losing the school nurse, what does that mean for kids with chronic illnesses who need meds and other attention during the school day?

Do something today that you think MLK would be proud of. We can all be better. Jennifer

What you lose if reform is repealed

Today's editorial in the NY Times spells it out here.

Americans will pay a high price if opponents get their way. Reform means that tens of millions of uninsured people will get a chance at security; and many millions more who have coverage can be sure they can keep or replace it, even if they get sick or lose their jobs.

Repeal would also take away the best chance for reining in rising health care costs — and the government’s relentlessly rising Medicare burden.

The nonpartisan Congressional Budget Office estimated that repealing the reform law would drive up the deficit by $230 billion over the first decade and much more in later years.

* * *

Many individuals and businesses are already benefiting from reform, and they will benefit even more once it goes into full effect in 2014.

Thanks to reform, it is now illegal for insurance companies to deny children coverage because they have pre-existing medical conditions, or to rescind a policy after a person becomes sick, or to cap the amount that insurers will pay for medical care over a lifetime. After 2014, it will be illegal for insurers to set annual limits on the amount they will pay for medical care or deny coverage to adults with pre-existing conditions.

Young people are now allowed to remain on their parents’ policies until age 26. And insurers are now required to cover preventive care in new policies without cost-sharing, and to spend at least 80 percent of their premium income on medical care and quality improvements, not profits or administrative costs. Repeal would eliminate all of these new protections.

Repeal would also eliminate federal tax credits that are helping small businesses provide coverage to employees as well as a reinsurance program that is helping more than 4,700 employers, large and small, provide health coverage to early retirees.

Read the whole piece and then decide. Jennifer

Health Reform is a Moral Imperative

Paul Krugman says that the divide in America is not about politics; it's about morality. Those of us who are in favor of health reform believe that the safety net is a moral imperative. We believe that "wealthy nations . . . have an obligation to provide all their citizens with essential care." The opponents believe that "people have a right to keep what they earn, and that taxing them to support others, no matter how needy, amounts to theft."

There’s no middle ground between these views. One side saw health reform, with its subsidized extension of coverage to the uninsured, as fulfilling a moral imperative: wealthy nations, it believed, have an obligation to provide all their citizens with essential care. The other side saw the same reform as a moral outrage, an assault on the right of Americans to spend their money as they choose.

This deep divide in American political morality — for that’s what it amounts to — is a relatively recent development. Commentators who pine for the days of civility and bipartisanship are, whether they realize it or not, pining for the days when the Republican Party accepted the legitimacy of the welfare state, and was even willing to contemplate expanding it. As many analysts have noted, the Obama health reform — whose passage was met with vandalism and death threats against members of Congress — was modeled on Republican plans from the 1990s.

But that was then. Today’s G.O.P. sees much of what the modern federal government does as illegitimate; today’s Democratic Party does not. When people talk about partisan differences, they often seem to be implying that these differences are petty, matters that could be resolved with a bit of good will. But what we’re talking about here is a fundamental disagreement about the proper role of government.

This seems right to me. And you know what side I'm on. I would not spend my entire life working to help others if I did not believe that doing so is a moral imperative. We cannot have people getting sicker and sicker because they were one of the millions who were laid off due to the recession. Not only is that cold, but it's stupid -- people left untreated get sicker, and when their illness spirals out of control, they end up in an emergency room where the taxpayers foot the bill when they can't.

I guess that's my only disagreement with Krugman -- health reform makes sense from an economic point of view, not only from a moral one. Jennifer

It's Friday Edition

And so we've just about made it through another week -- an especially tough one, starting with a horrific shooting, and then being marked by a record snowfall. We've earned a week-end. But before we kick off our shoes, here's a little news.

The health reform repeal vote has been rescheduled, but the rhetoric has been toned down, and the GOP promises an issues-oriented debate. Meanwhile, a new poll finds Americans evenly split on the new law.

The Centers for Disease Control released a report on racial disparities in health care that's quite stark and scary. Higher suicide rate. Higher infant mortality rate. Higher rate of drug overdoses. Higher rate of death from heart disease. More high blood pressure. On and on. Clearly, this documents something that must be addressed.

The remarkable Pauline Chen writes about a hospital program designed to end violence by working to heal the victims both emotionally and physically, and reaching out to the community to at risk kids who have not yet been touched by violence. Inspiring.

The FDA will limit the amount of acetaminophen (Tylenol) that can be in Vicodin, Percocet due to liver damage. The manufacturers have 3 years to reformulate the meds or take them off the market. I can't imagine entirely losing these incredibly effective, important pain meds, so I hope the manufacturers can find a work-around.

Although California law says no more gender rating (i.e., higher premiums for women) as of January 1, the LA Times reports that this hasn't quite taken hold yet.

And that's what I have for you this morning. Have a good one. Jennifer

Health Reform Repeal Vote Rescheduled

The vote on repealing health reform has been rescheduled. Debate will begin on Tuesday night and the vote will take place on Wednesday evening. Jennifer

It's Entirely Up to Us

For months now, I have been deeply troubled by the tone of our public discourse. Since the real vitriol started last summer when the Tea Party took aim at health reform, I think it's appropriate to talk about this here.

How did a desire on the part of many Americans to make sure that everyone has access to health care become such a divisive issue? Part of it is misinformation. For example, the claim that health reform amounts to a government take-over of health care is completely false. First, there's already Medicare, Medicaid, military health care, and so on. Second, the health reform bill is premised on the notion that private insurance companies will remain private insurance companies, and we consumers still get to buy from whichever insurance company we choose. People carrying signs last summer saying "get your government hands off my Medicare" evinced a lack of understanding, since Medicare is a federally administered and funded program. The misinformation -- which has been spread quite actively by FOX News and others -- made it impossible for us to have a rational discussion. We were talking apples and oranges.

It seemed to snowball from there, though. People bringing weapons to town hall meetings. People painting Hitler mustaches and white-face on photographs of the President of the United States. People shouting so as to drown out those with whom they disagree.

I'm prepared to agree, for the sake of discussion, that the rhetoric became personal and heated on both sides of the debate. I think it gets us nowhere to argue whether the Tea Party is more responsible for this than Ed Schultz. When Rush Limbaugh says that the Tuscon shooter has the full backing of the Democratic party, that's just plain disgusting. But it would be no less disgusting if Keith Olberman said the shooter had the support of the GOP.

Sarah Palin says that vigorous debate has always been part of American democracy. Not like this, though. Not to where we accuse the President of the United States of being "hell-bent on weakening America" -- a charge that pretty well amounts to an allegation of treason.

When discussions of health care reform bleed into discussions of who's worse, the Tea Party or the Black Panthers or ACORN or whomever, we've lost the ability to have a discussion in this country that can lead to acceptable compromise. Indeed, mostly out of the public view, there was a lot of compromise on health care reform. We on the left gave up the public option -- grudgingly, but with the understanding that we had to give something up to get what we ultimately got. The right pushed for some things it got, as well -- strong restrictions on the use of federal funds for abortion, express language that illegal aliens could not get health care, to name the two most talked about. Indeed, one of the reasons the American people are evenly split on the wisdom of health reform is that it represents an imperfect compromise that isn't completely what anybody wanted. The public notion that this was something the left shoved down the "people's" throats simply is false. Senator Baucus made compromises to get the GOP's Olympia Snowe's vote in the Finance Committee. The White House made compromises with the insurance industry and the pharmaceutical industry. There are huge differences between the more liberal bill that came out of the Senate Health, Education, Labor and Pensions Committee and the more moderate bill that was passed in the end.

And really, in any event, how does it help us to focus on blame?

I think the President's speech in Tuscon last night found exactly the right tone. He said that the lack of civility in America didn't cause the shooting, but it does get in the way of our democracy, which is dependent on the ability to have open and honest discourse. He said that we can do better as a country than to allow our public discourse to deteriorate into verbal attacks. He said that, "when it comes to how we treat each other, it's entirely up to us." And that means we must take responsibility for treating each other with the respect that all of us deserve.

The solution to what happened in Tuscon is not to "wish there was one more gun in Tuscon" to use to shoot the shooter. The answer to violence is not more violence. The shooting in Tuscon should remind us all of how out of control things can get when we allow our discourse to become unfettered by common decency. When it becomes the norm to make fun of the President or to flat out lie about current events or to engage in baseless name-calling, we all lose. When we are unable to have a civil discussion about the merits and detriments of health reform because we are too busy throwing invectives at each other, we become polarized, as we have done.

We can do better, and we should not wait for our political leaders to set the example. We should start treating each other with respect immediately. I vehemently disagree with those who oppose health reform. But I'm prepared to talk about what parts of it can be changed, should be changed, if the opponents are willing to have that same discussion.

Last year, I was on a panel on health reform at the University of Connecticut Law School. A gentleman in the audience said he thought that insurance companies are evil, that they deny claims and delay decisions in the hope that people will just die and no longer cost them money. I responded strongly that I don't believe that is true, and I don't. The people I know who work at health insurance companies don't intend to cause harm, although I know that there are terrible problems communicating with insurance companies, which make it hard to believe sometimes that they are well-intentioned. But let's talk about it in terms of the problems with decisions they make and how they make them rather than ascribing to them an intent to cause harm. Let's solve the problem without even trying to figure out whose fault the problem was in the first place.

I'm not anywhere near as articulate as President Obama. If you didn't hear his speech last night, I hope you will watch the video or read a transcript. He said what I'm trying to say far better than I ever can say it. But I think that, the more we try to engage in civil discourse, the more we commit to being respectful, the better our democracy will function. The health of our democracy depends on it. Jennifer

Calm After the Storm Edition

We got the most snowfall in a 24 hour period EVER recorded at Bradley Airport. Quite something. But the world keeps turning and things keep happening.

Most of the news this morning relates to the tragedy in Tuscon, and especially the President's eloquent speech last night. There's only a smattering of health news today.

JP Morgan is holding a health care conference to talk to businesses about the opportunities inherent in health reform. Investors are optimistic about how reform will impact health insurers.

Health reform will bring a major expansion of mental health care. People who become insured will be able to afford mental health care for the first time. Perhaps this will help to curtail mental illness before it leads to violence.

A new study shows that the lower drug copays are, the more people are able to avoid hospitalizations and complications. When people can afford their meds, they take their meds, and that keeps them healthier and keeps their medical costs down overall.

Will medical innovation reduce health care costs? Some say yes, and they lay out a cogent argument.

The USDA is calling for dramatic changes in school lunches, with the first increase in nutrition standards in 15 years. Good.

Meanwhile, the cost of caring for cancer balloons. It could hit $207 billion by 2020.

And that's it for now. I'm off to brave the frozen tundra in search of my morning swim. Jennifer

Blizzard Edition

No snow day for me since I work from my home. But it's a complete white-out outside my window, and there's even lightning and thunder. Nobody's going anywhere today except virtually.

So here's the news.

Politico speculates that the tragedy in Arizona may help soften the health care debate. That would be most welcome. We need to be able to have a debate in this country without drawing Hitler mustaches on our President, or bulls-eyes on Congressional districts.

Still, the GOP seems determined to repeal or -- if necessary -- gut the health reform bill.

Meanwhile, the shooting in Arizona has sparked new calls for better understanding of mental health issues in the hope that attacks like this can become more predictable.

Health economists say that the seeds of health care cost containment are in the reform bill. So if we don't carelessly repeal, and instead study and expand the cost containment measures that work, we may actually begin to rein in costs.

It's flu season. Doctors are urging people to get a flu shot -- especially those with chronic illnesses and the elderly. I got mine in October!

A new Kaiser Family Foundation report says that, even while States struggled with budget deficits, health care for poor kids was maintained due to increased federal reimbursement for Medicaid.

And here's a first-hand account of the barriers for medical students who want to go into primary care, and some of the things that might help. One thing that won't help is a court ruling that medical residents are employees, subject to paying Social Security tax, rather than being classified as students.

The Supreme Court ruled 7-2 that Congress can prohibit felons from wearing body armor like bullet proof vests. What does this have to do with health care, you ask? The pundits are saying that the Court seems not to want to curtail Congress's power to regulate commerce -- the very power that underlies the health reform law. So the commentators are saying that this ruling looks good for health reform. We'll see.

Meanwhile, the California Insurance Commissioner is taking a hard look at some very large premium increases that he thinks may be excessive. We hope other states will follow.

A new study shows a connection between second-hand smoke and high blood pressure in kids. If I could quit a 3 pack a day habit after 20 years, so can you!

And here in Connecticut, the SustiNet Board has submitted its final report to the legislature. SustiNet is Connecticut's version of health reform that would work with federal reform to increase coverage to many who cannot afford alternatives. SustiNet would be a health plan for state employees, Medicaid and CHIP recipients, and ultimately municipalities and small businesses that would provide comprehensive coverage at a lower cost because the risks would be spread over a much larger pool. The obstacle is cost, although some proponents believe SustiNet would actually save the State money by doing what the State already has to do but for less money.

And that's the news on a day when the weather eclipses everything else. Brrrrr. Jennifer

Chamber of Commerce Backs Repeal

No surprise to those of us who've been following the details, the US Chamber of Commerce -- NOT the same as your local chambers of commerce -- is supporting repeal of the health reform legislation. Although they had promised not to lobby against it any more, they now have come right out with what we all knew was true all along -- they are against reform and in favor of repeal. They say the fact that the federal government has granted waivers to some businesses shows that the law is unworkable. Seems to me that flexibility and case-by-case evaluation shows that the law is eminently intelligent. Jennifer

Tuesday News

I thought maybe we could use a little amusing strangeness this morning, so here's a story about the crazy things people swallow.

As we all try to regain our composure after this week-end's shootings, some remind us that the current truce over health reform is temporary. I hope that, when the discussion resumes, the tone is a bit toned down -- but I'm not counting on it.

And nobody's slowing down implementation. The Obama Administration is working on regulations that lay out the essential benefits package -- the minimum that every plan must cover -- trying to strike a balance between medical needs and costs.

But for the moment, at least in Congress, health reform is off the front burner, so here's a smattering of other health news.

The brilliant Jonathan Cohn talks about what happens when the FDA rules against a particular use of a drug. Is this the rationing that the right has been screaming about? The FDA has been doing this for decades, so we know it's not part of health reform. Still, some argue as if it were. What do you think?

Did you know that a fever in a child can be proof of an adequate immune system? Good to know.

One of the biggest problems in health care is how to keep people to their drug regimen. So how about pills that remind you to take them? And what about ways around injections and infusions for drugs you can't swallow?

A new study shows that specialists and primary care docs don't communicate as well as they need to for their patients.

The three technologies caregivers want most: a personal tracker, a medication reminder, and a caregiver coordination scheduler.

Patients ordering their own labs? Really?

Gail Sheehy on end of life planning.

Obese fibromyalgia patients suffer more than those at a lower weight.

Some insight into how cancer grows.

The road to heart disease begins in childhood.

Should public hospitals be allowed to sue pharmaceutical companies for not granting discounts? The Obama Administration says yes because of concern over a wave of lawsuits. But what about the poor patients?

A touching story -- an amputee who started a foundation to help other amputees pay for bionic prostheses.

Your mom was right -- breakfast is the most important meal of the day. So do it right.

And that's a broad and unsystematic overview of what's in today's news. Have a safe day. Jennifer