Daily Health Policy Report

Monday, September 30, 2013

Last updated: Mon, Sep 30

KHN Original Reporting & Guest Opinion

Capitol Hill Watch

Health Reform

Health Care Marketplace

State Watch

Editorials and Opinions

KHN Original Reporting & Guest Opinion

In Kentucky, Confusion And Misinformation Abound On Eve Of Obamacare Rollout

Kaiser Health News staff writer Phil Galewitz, working in collaboration with The Washington Post, reports: "On a late September night – just days before the Oct. 1 launch of the state's online health insurance marketplace called Kynect -- most passersby are unaware of their new health insurance options under the law, confused by the political sniping and doubtful the law will help them. … Politically divided,  Kentucky is the only southern state running its own Obamacare marketplace and one of just two committed to expanding Medicaid, making it a unique bellwether of public receptivity to the law.  While Gov. Steve Beshear is a Democrat, its two senators, Senate Minority Leader Mitch McConnell and Rand Paul, are Republicans and ardent foes of Obamacare" (Galewitz, 9/29). Read the story and a related Q & A with Kentucky Gov. Steve Beshear (9/29).

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Three Critical Measures Of Marketplaces’ Impact Could Take Several Years To Assess

Kaiser Health News staff writer Jordan Rau reports: "Rev your engines: On Oct. 1 people can start shopping for insurance on the new on-line marketplaces created by the health law. The first weeks and months will be closely watched, but many policy experts say don't speed to judgment on how well they are working. While people can enroll for insurance until the end of March, real assessments of these marketplaces will take months if not years" (Rau, 9/29). Read the story.

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Where You Live Determines How Much You Pay For Health Insurance

Kaiser Health News staff writers Julie Appleby and Jordan Rau, working in collaboration with The Philadelphia Inquirer, report: "When buying health insurance, where you live matters. In Pennsylvania and more than a half dozen states, consumers in some cities will pay at least 50 percent more for the same type of coverage than their friends and relatives in other parts of the state" (Appleby and Rau, 9/29). Read the story and check out a related chart, Monthly Premiums For A 'Benchmark' Silver Plan In Federally Run Insurance Marketplaces.

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Capsules: Poll Finds Most Unaware of Tuesday Opening of Health Insurance Marketplaces; Medicare To Delay Enforcement Of New Observation Rule

Now on Kaiser Health News’ blog, Jordan Rau reports: "A new poll finds a majority of the public — especially those lacking health coverage — is unaware that new insurance marketplaces created by the health law are slated to open next week. The poll also found deep skepticism of media coverage of the law, with more than half the public saying they don't trust any media source to provide credible information" (Rau, 9/29).

Also on the blog, Susan Jaffe reports on a delay in the enforcment of the Medicare observation rule: "Medicare officials announced Thursday that they will delay enforcement of controversial new rules that define when hospital patients should receive observation care, rather than being admitted, a distinction that makes beneficiaries ineligible for follow-up nursing home coverage" (Jaffe, 9/27). Check out what else is on the blog.

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Political Cartoon: 'Rite Wing?'

Kaiser Health News provides a fresh take on health policy developments with "Rite Wing?" by Clay Bennett.

Here's today's health policy haiku:


Congressional fight?
Feh! A shutdown can't compete
With Homeland premier!

If you have a health policy haiku to share, please send it to us at http://www.kaiserhealthnews.org/ContactUs.aspx and let us know if you want to include your name. Keep in mind that we give extra points if you link back to a KHN original story.

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Capitol Hill Watch

Battle Over Health Law Brings Gov't To Brink Of Shutdown

A stopgap bill to fund the government when the fiscal year ends Oct. 1 continues to be caught up in Republican efforts to defund, delay or derail the health law. Federal agencies have contingency plans in place.

The New York Times: Senate Action On Health Law Moves To Brink Of Shutdown
The Senate is expected to reject decisively a House bill that would delay the full effect of President Obama’s health care law as a condition for keeping the government running past Monday, as Senator Harry Reid, the Democratic majority leader, expressed confidence that he had public opinion on his side. Angering Republicans who lead the House, Mr. Reid kept the Senate shuttered on Sunday, in a calculated move to stall action on the House measure until Monday afternoon, just hours before the government’s spending authority runs out at midnight (Peters and Weisman, 9/29).

The Wall Street Journal: Government Heads Toward Shutdown
The nation braced for a partial shutdown of the federal government, as time for Congress to pass a budget before a Monday midnight deadline grew perilously short and lawmakers gave no signs Sunday they were moving toward a resolution. ... House Speaker John Boehner (R., Ohio) urged Senate leaders to pass legislation that the Republican-controlled House had approved early Sunday morning, which would fund the government through mid-December. But that prospect was remote, as the House legislation included a one-year delay of the new federal health law that Democrats have vowed to reject, as well as a repeal of the new law's tax on medical devices (Hook and Peterson, 9/29).

The Associated Press: Who'll Blink? Dems, GOP In Shutdown Stare Down
With the government teetering on the brink of partial shutdown, congressional Republicans vowed Sunday to keep using an otherwise routine federal funding bill to try to attack the president's health care law. ... Since the last government shutdown 17 years ago, temporary funding bills known as continuing resolutions have been noncontroversial, with neither party willing to chance a shutdown to achieve legislative goals it couldn't otherwise win. But with health insurance exchanges set to open on Tuesday, tea-party Republicans are willing to take the risk in their drive to kill the health care law (Taylor, 9/29).

Politico: Obamacare Medical Device Tax Assumes Big Role In Spending Battle
Along with a one-year delay in the president’s health law, House Republicans have included provisions repealing the 2.3 percent tax on medical devices in their bill to fund federal agencies into the next fiscal year. And some have suggested the move to wipe out that tax might — at some point— become a path to compromise with the Senate. But Senate Democratic leaders have so far opposed the device tax as part of a short-term spending bill (Faler and Norman, 9/29).

The New York Times: Federal Agencies Lay Out Contingency Plans For Possible Shutdown
As Congress continued to spar on Saturday over a stopgap spending measure to keep the government running, federal agencies made contingency plans for a potential shutdown. ... Although more than half of the Department of Health and Human Services would be furloughed, Medicare and Medicaid beneficiaries would continue to receive services. Retirees would continue to get checks from the Social Security Administration. The rollout of President Obama’s health care law, with the first insurance marketplaces to go online starting on Tuesday, would continue because most of the money for that program was provided by the Affordable Care Act and other laws (Schmidt, Shanker and Siddons, 9/28).

CQ HealthBeat: More Than Half Of HHS Employees Would Be Furloughed In Shutdown
If the federal government shuts down next week, the Department of Health and Human Services’ contingency plan calls for furloughing more than half of its 78,198 employees. Services such as the Centers for Disease Control and Prevention’s flu program and the majority of the Food and Drug Administration’s food safety activities would be suspended, according to a plan the agency posted on its website late Friday (Bunis, 9/27).

In other congressional action -

Reuters: U.S. House Passes Bill To Regulate Drug Compounding
The U.S. House of Representatives on Saturday passed legislation that would give the Food and Drug Administration more authority to regulate companies that compound sterile drugs and ship them across state lines. The bill, called the Drug Quality and Security Act, now goes to the Senate for a vote. House and Senate committees agreed on the legislation on Wednesday (9/28).

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Health Reform

Health Exchanges Set To Launch Oct. 1 Amid High Stakes And Political Pressure

Politico predicts that Tuesday will be a split-screen day -- tracking developments related to the government shutdown and launch day of the health law's online marketplaces. Those who are watching the insurance exchanges note that it may be months after opening day, even years, before it's possible to assess how well they are working. 

Politico: As Government Shutdown Looms, Obamacare Exchanges Still Set For Launch
It's looking more and more like Tuesday will be a split-screen day: The government will shut down, and Obamacare will open for business. That's going to annoy a lot of Republicans -- because the ones who are pushing the shutdown are doing so precisely because they want to halt Obamacare (Cunningham and Nather, 9/29).

Los Angeles Times: As Key Parts Of Obamacare Kick in, Stakes Are High For Both Parties
The debate over President Obama's signature health care law enters a crucial phase this week as the real effect on consumers starts to come into focus after more than 3 1/2 years of partisan claims and counter-claims. For both sides in the protracted battle over what has come to be called Obamacare, it is a moment of political peril (Levey, 9/29).

Bloomberg: Obamacare's Latino Push May Give Democrats Political Edge
The battle over Obamacare is taking on political importance as Democrats hope a successful roll-out among Hispanics will further bind those voters to the Democratic Party and undermine Republican efforts to build more support before the 2016 presidential election. In California, where Hispanics will outnumber whites within a year, backers of the Affordable Care Act are ramping up outreach in places like Richmond, a San Francisco Bay Area city whose population is almost 40 percent Hispanic and where about 18 percent of residents live below the poverty line (Vekshin, 9/30).

The New York Times: U.S. Plans To Unveil New Insurance Options
The Obama administration plans on Monday to announce scores of new health insurance options to be offered to consumers around the country by the Blue Cross and Blue Shield Association and the United States Office of Personnel Management, the agency that arranges health benefits for federal employees, according to administration officials. The options are part of a multistate insurance program that Congress authorized in 2010 to increase options for consumers shopping in the online insurance markets scheduled to open on Tuesday (Pear, 2/29).

The New York Times: On The Threshold Of Obamacare, Warily
The insurance marketplaces that form the centerpiece of President Obama’s health care law are scheduled to open on Tuesday, a watershed moment for the Obama administration, but also a crucial turning point for millions of Americans who will finally get the chance to square the law’s lofty ambitions with their own personal needs. While some people desperate for coverage will need no persuading to sign up, for others the decision will amount to a series of complicated calculations that would challenge an accounting whiz, let alone an ordinary human (Thomas and Abelson, 9/28).

Kaiser Health News: Three Critical Measures Of Marketplaces' Impact Could Take Several Years To Assess
Rev your engines: On Oct. 1 people can start shopping for insurance on the new on-line marketplaces created by the health law. The first weeks and months will be closely watched, but many policy experts say don't speed to judgment on how well they are working. While people can enroll for insurance until the end of March, real assessments of these marketplaces will take months if not years (Rau, 9/29).

NPR: One Key Thing No One Knows About Obamacare
Tuesday is a big day for Obamacare. The online marketplaces where people can shop for health insurance are supposed to open for business. No one really knows who is going to sign up -- not the Obama administration, not the insurance industry, not the president's critics. Yet the success of the law hangs on this question: Will the right mix of people sign up? In particular, will healthy people buy health insurance? (Kestenbaum, 9/30).

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Concerns About Technical Snags On Marketplace Opening Day

Advocates and foes of health law agree that technical glitches could create some problems.

The Wall Street Journal: Health Law Hits Late Snags As Rollout Approaches
Obama administration officials scrambling to get the health law's insurance marketplaces ready to open on Tuesday keep hitting technical problems, while government-funded field workers across the country say they aren't fully prepared to help Americans enroll in the program (Weaver, Martin and Radnofsky, 9/29).

The New York Times: As Opening Day Nears, Insurance Exchanges Scramble To Prepare
Tuesday is the long-awaited kickoff for President Obama's signature health care law, when millions of Americans can start signing up for new insurance options. Yet across the country, officials are issuing warnings that despite fevered efforts, their new insurance exchanges — online markets where people can shop for health plans and see if they qualify for federal subsidies — will not be fully operational for weeks or even months (Goodnough, 9/29).

The Wall Street Journal: 'Lego' Model For Exchange Software
Pradeep Goel arrived from India 23 years ago to study in America. On Tuesday, Mr. Goel, now chief executive of a fast-growing technology company, faces his toughest examination yet: Making sure the software behind two new health-insurance exchanges doesn't crash. ... For the state exchanges to work, normally separate computer systems have to talk to each other and it is EngagePoint Inc.'s job to build software bridges between those systems (Corbett Dooren, 9/29).

Reuters: Race To Get Obamacare Online Sites Running Goes To The Wire
Just days before the launch of the new U.S. state health insurance exchanges that are the centerpiece of the Affordable Care Act, a nationwide push is still under way to test and patch the technology behind the online sites. Officials working on the sites have acknowledged that information technology (IT) failures will prevent many of them from functioning fully for weeks, and perhaps longer (Begley, 9/28).

The Hill: Barrasso: 'Duct Tape And Chicken Wire' Holding Obamacare Exchanges Together
Sen. John Barrasso (R-Wyo.) on Sunday said that ObamaCare insurance exchanges set to go live this week "are being held together right now with duct tape and chicken wire" (Balluck, 9/29). 

The Hill: Dean: 'There Are Going To Be Some Glitches' With Obamacare
Former Vermont governor and Democratic presidential candidate Howard Dean acknowledged Sunday that there are "going to be some glitches" with President Obama's healthcare law (Pecquet, 9/29). 

Meanwhile, a different kind of potential glitch -

Medpage Today: ACA Countdown: Expect Low Pay For Docs In Exchange Plans
National physician groups are concerned the rates are so low that their members won't sign on to participate in ACA marketplace plans, and there will be no doctors to treat those newly covered patients. A representative of one primary care provider organization, speaking to MedPage Today on background, said some rates were 70 percent lower than traditional preferred provider network plans, adding that plans were trying to make provider rates as low as possible to keep premiums equally low (Pittman, 9/27).

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For Consumers Shopping For Insurance On New Health Exchanges, A Lot Will Be Determined By Where They Live

People who live in states where officials were less enthusiastic about the health law's new online marketplaces will likely have to look harder to find information about them. Meanwhile, coverage costs will vary widely, not just from state to state, but sometimes among cities and regions within the same state.

The Associated Press: States Resist, Build Nascent Insurance Markets
With new online health insurance exchanges set to launch Tuesday, consumers in many Southern and Plains states will have to look harder for information on how the marketplaces work than their counterparts elsewhere (Dalesio, 9/29).

Kaiser Health News: Where You Live Determines How Much You Pay For Health Insurance
When buying health insurance, where you live matters. In Pennsylvania and more than a half dozen states, consumers in some cities will pay at least 50 percent more for the same type of coverage than their friends and relatives in other parts of the state (Appleby and Rau, 9/29).

Meanwhile, news outlets offer progress reports from California, Minnesota, Kentucky, Missouri, Washington and Wisconsin.

Los Angeles Times: California Insurance Exchange Chief Has Health Reform 'In His Bones'
Republicans in Congress are railing against the healthcare law as a government takeover of medicine. The massive program will harm patients and cost far too much, critics say. ... It mirrors the scene 50 years ago during the contentious debate over Medicare. Two brothers, Peter and Philip Lee, fought on the front lines back then, bucking the medical establishment to guarantee healthcare for seniors. Now another Peter Lee — Peter's son and Philip's nephew — is carrying on the family tradition. He's in charge of enrolling millions of Californians in Obamacare (Terhune, 9/28).

The Sacramento Bee: California Relying On 'Guerrilla' Tactics To Sell Obamacare
Much of the nation is watching California’s rollout given the size of the state and the fact it has, at 20 percent, one of the highest state rates of uninsured residents. At a stop this summer in San Jose, President Barack Obama held up the Golden State’s online marketplace and the immense machinery behind it as a model, touting its efforts to steer Latinos and other groups with high rates of uninsured toward the exchange. The uninsured are in many ways more difficult to reach than other consumers, so the state is turning to less-traditional approaches – visiting people in homes, clinics, churches and other places where non-English speakers and the underemployed might congregate (Cadelago, 9/30).

Pioneer Press: MNSure Launches Tuesday, And State Hopes For Smooth Sailing
Following years of partisan rancor, millions in development costs, endorsements by a mythical lumberjack and a handful of controversies, Minnesota on Tuesday hopes to launch ... a website. If it works, the website will give thousands of individuals and small businesses a new option for buying health insurance (Snowbeck, 9/29).

MinnPost: Some MNsure Problems Appear Worse, But Officials Say They're Set To Launch Tuesday
MNsure's latest internal reviews show staff continuing to identify serious problems with the project, and the status of the health exchange appears worse off now than it was weeks ago as Tuesday's launch approaches. Since MinnPost began receiving internal documents — which include weekly project status reports, technical documents and risk assessments — in early September, three of seven areas that MNsure staff and vendors are consistently working on have been deemed worse off than before (Nord, 9/27).

Minnesota Public Radio: Health Exchange Rollouts Are A Milestone For 'Obamacare'
[Former Gov. Tim] Pawlenty could have been the father of MNsure, the state's health plan marketplace. Six years ago Pawlenty, a Republican, wanted to create a non-profit Minnesota Insurance Exchange, an approach he said would make insurance less expensive for workers and lower costs for employers. ... Four years later, Pawlenty was running for president and like all of the GOP hopefuls too, took shots at Obamacare, which relies heavily on the exchange concept. ... As Pawlenty's term as governor neared an end, he turned down a $1 milllion federal grant to start planning a Minnesota exchange. But after Gov. Mark Dayton, a Democrat, took office in January 2011 the federal development dollars started flowing into Minnesota -- over GOP objections (Stawicki, 9/30).

Minnesota Public Radio: Why MNsure Rates Are The Lowest In The Country
Plans offered on MNsure will have the lowest premium rates in the nation, according to research done by the U.S. Department of Health and Human Services and the Minnesota Department of Commerce. Uninsured Minnesotans in the Twin Cities can expect to pay as little as $91 a month for health care coverage bought through the state's new online marketplace. Rates will be more expensive for those who want a more robust insurance plan, and for those who are buying insurance for a family or employees in small business (Richert, 9/27).

The Star Tribune: Insurance Exchange Will Force Choices
MNsure and other state exchanges across the country are a critical element of the federal health care law known as Obamacare. Even as controversy continues to rage around the law, its final rollout in the coming months will bring a sharp change in how millions of Americans pay for health care. While most people will still get insurance through an employer, those who shop on MNsure will decide for themselves which insurance company to use, how much coverage to get and what they’re willing to spend (Crosby and Olson, 9/29).

Kaiser Health News: In Kentucky, Confusion And Misinformation Abound On Eve Of Obamacare Rollout
On a late September night – just days before the Oct. 1 launch of the state's online health insurance marketplace called Kynect -- most passersby are unaware of their new health insurance options under the law, confused by the political sniping and doubtful the law will help them. … Politically divided, Kentucky is the only southern state running its own Obamacare marketplace and one of just two committed to expanding Medicaid, making it a unique bellwether of public receptivity to the law. While Gov. Steve Beshear is a Democrat, its two senators, Senate Minority Leader Mitch McConnell and Rand Paul, are Republicans and ardent foes of Obamacare (Galewitz, 9/29).

St. Louis Post-Dispatch: Health Insurance Marketplaces Offer New Opportunities
Nathan Brown and Allyson Harper of south St. Louis embody the opportunity and uncertainties in the air as new health insurance marketplaces open for business. … Starting on Tuesday, the Affordable Care Act's open enrollment period begins across the United States for new state- and federal-run online marketplaces (Doyle, 9/28).

St. Louis Beacon: Health Exchange Martketplace Is Set To Open; Consumers Told To Walk Not Run To It
Business is good at the Pilates and Yoga Center in Ladue. But an issue that continues to interrupt the peace of owner Karen Prechtl is affordable health insurance for herself and her 10 employees. ... GOP critics, such as Lt. Gov. Peter Kinder and House Speaker Tim Jones of Eureka, say the system is flawed and unclear. Supporters note that the marketplaces haven't even opened yet (Joiner, 9/30).

The Milwaukee Journal Sentinel: State Says It’s Ready To Help Thousands Negotiate Obamacare Changes
As Tuesday's start date for the federal health care law approaches, Gov. Scott Walker's administration say it's ready for the hundreds of thousands of Wisconsinites who will have new options for shopping for health coverage. In one key part of that process, the state's deputy health services secretary said Friday he is now confident that federal officials will approve covering low-income childless adults through the state's BadgerCare Plus program (Stein, 9/27).

The Seattle Times: Obamacare: State Says It's Ready For Big Day
Years of debate, planning, education and outreach have come down to this: On Tuesday, Washington state residents — and people across the country — can begin buying health insurance in exchanges created under Obamacare, or the Affordable Care Act. Aimed at the uninsured and those who have individual health-insurance policies, the online exchanges are a key part of the health-care overhaul President Obama signed into law in March 2010 (Landa and Marshall, 9/29).

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Navigating The Health Law's New Insurance Options

In some states, the task of helping consumers find their way through the health law's new online insurance marketplace has fallen to "navigators." In general, though, news outlets report on the strategies and public outreach efforts underway in locations across the country.  

The Associated Press: S. Texas Provides Gauge On Health Care Law Impact
Promoters of the new federal health care law have spent months crisscrossing border communities in South Texas, speaking to church congregations and making presentations in community centers where some of the nation's largest pockets of uninsured can be found (9/29).

The Associated Press: Florida Pushes Health Care Law Education
With less than 24 hours until the launch of one of the key components of the new federal health law, hundreds of health counselors and volunteers are fanning out across the state, knocking on doors, working phone banks and manning tables at concerts and sporting events to tell people how to sign up for health insurance under the Affordable Care Act (Kennedy, 9/29).

The CT Mirror: Pitching Obamacare In Hartford, Home Of 34,000 Uninsured
With about 3.4 percent of the state's population, Hartford is home to close to 10 percent of Connecticut’s uninsured. And so, as efforts intensify to get the state’s uninsured covered through new options becoming available under the federal health reform law, Hartford Mayor Pedro Segarra has charged the agencies he oversees with making a special push to reach "the Hartford 34,000” (Becker, 9/30).

The Philadelphia Inquirer: Becoming A Navigator Is No Simple Matter
It happened during the exam for Eligibility and Enrollment--an SAT flashback. I was back in high school baffled by questions with multiple-choice answers so nuanced they would fluster a philosopher. … But this wasn't the SATs. I was testing to become a navigator. Not one who directs airplanes, ships, or that annoying GPS voice that continually says "recalculating." No, I was studying to become a navigator for the Affordable Care Act (Calandra, 9/29).

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Tips For Shopping On New Obamacare Exchanges

Media outlets offer guides to the uninsured and to those who buy their own coverage on the eve of the startup of new online marketplaces under the federal health law. The marketplaces, which launch Oct. 1., are designed to allow millions of people to shop for insurance and to find out whether they qualify for tax credits to buy private insurance, or an expanded Medicaid program.

NPR: Insurance Exchange 101: Here's What You Need To Know
The Affordable Care Act has been through two years of legislative wrangling, a presidential election and a Supreme Court test that took it to the brink. Now, after yet another round of debate and argument, major pieces of the federal health law are expected to kick in Tuesday. If all goes as planned, people who don't have insurance or who buy it on their own will be able to shop online or at various locations in their communities for coverage that will take effect Jan. 1 (Rovner, 9/30).

USA Today: Exchanges Open Tuesday: Here's What To Do
Don't wait. But don't hurry either. That's the best approach to the new health insurance exchanges that are scheduled to open for business Tuesday. Buying insurance is supposed to be easier than ever once several provisions of the Affordable Care Act take effect this fall. That doesn't mean the process is easy or should be done speedily, however, experts say. That's especially true if insurance shopping is new to you (O'Donnell and McGinnis, 9/29).

The Wall Street Journal: What Does New Health Law Mean For Me?
The rollout of the Affordable Care Act—also known as "Obamacare"—is approaching, and starting in October people will be able to sign up for new insurance policies that begin Jan. 1, when the law's major provisions are set to go into effect. Here's what you need to know about whether and how the law affects you (Radnofsky, 9/29).

Tampa Bay Times: Q&A: Medicare And The Marketplace
Health policy experts and advocates have worried for months that older and disabled Americans who get their insurance through Medicare could get swept up in all the talk about the new Obamacare marketplaces. Though myths about Medicare have featured prominently in the health care debate, the fact is that the marketplaces have virtually no impact on how older and disabled Americans will buy their insurance (Sutton, 9/29).

ABC News: Best Tips For Finding The Most Affordable Plan In Your State’s Health Exchange
On Oct. 1, Americans can start shopping for health insurance plans through the Affordable Care Act, also called Obamacare. Use this guide to understand the basics every health insurance shopper needs to know (LaMontagne, 9/30).

The Oregonian: Oregonians See Health Reform Wrinkles Emerge As Enrollment Begins
Even families pulling down decent money -- as much as $94,000 for a household of four -- likely qualify for tax credits, credits that could result in paying less next year than they do now. The whole system under the Patient Protection and Affordable Care Act -- better known these days as Obamacare -- is based on income and the ability of individuals to pay (Budnick, 9/28).

Bloomberg: Obamacare Exchanges Start As Questions Abound: Health Q & A
Obamacare’s insurance exchanges debut tomorrow and so far the run-up has looked a lot like a political campaign, with dueling TV ads, door-knocking volunteers and a focus on swing-state targets. Just don’t expect the usual ending to an election: a clear winner at the end of the day (Nussbaum, 9/30).

Miami Herald: What You Should Know Before Buying Insurance Online Tuesday
It’s the Patient Protection and Affordable Care Act, a.k.a Obamacare. And it’s finally arriving this week. On Tuesday, millions of people in Florida and across the United States will, for the first time, be able to log online and comparison-shop for individual health insurance coverage under the new federal law. Here are 10 things to know before the federal Affordable Care Act’s marketplaces go live (Benn, 9/28).

The Denver Post: You’ve Heard Change Is Coming With Obamacare; What Happens Next?
Key elements of the much-debated Affordable Care Act, or Obamacare, launch on Oct. 1. Are you ready? State insurance exchanges and the Medicaid expansion — the two main ways the new health-care law will extend health care to more Americans — will open for business (Booth, 9/30).

The Oregonian: New Health Law’s ‘Family Penalty’ Has Employees, Employers Mulling Change
On Jan.1, new Affordable Care Act rules allow employees to tap tax credits if their company plan is "unaffordable," meaning it costs 9.5 percent of income, or more. The catch? That calculation is based on employee-only coverage and doesn't include family members. If the employee coverage is affordable, but the dependent cost is more expensive, it creates the glitch. As long as a company offers to cover an employee's spouse and children, no matter how expensive it is, the spouse and child won't be allowed to tap the tax credits allowed under the law -- even if it would be cheaper for the family. This quirk has generated controversy in the heated debate over health care. What's gotten less attention is how firms and employees are taking advantage (Budnick, 9/29).

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Arkansas' Medicaid Expansion Plan To Cover 200,000 Through Private Coverage Approved

The federal government on Friday approved Arkansas' plan to take federal Medicaid expansion dollars to buy commercial health coverage for more than 200,000 people. Six other states may go similar routes.

The New York Times: One State's Way To Bolster Health Coverage For Poor 
Federal officials said Friday that they had approved a novel proposal from Arkansas to expand Medicaid by buying private coverage for poor people through the insurance marketplace being set up under the new federal health care law. The Arkansas program, expected to cover more than 200,000 people, sets a precedent of national significance. It offers a hybrid coverage plan calculated to appeal to Republicans, taking federal money for the expansion of Medicaid and using it to purchase commercial insurance (Pear, 9/27).

Reuters: U.S. Clears Arkansas Medicaid Expansion Proposal 
The U.S. government approved Arkansas' proposal to use federal money targeted for expanding the Medicaid health program for the poor to help low-income residents buy private insurance under President Barack Obama's health care law. The request was approved by the U.S. Centers for Medicare and Medicaid Services, the agency said on Friday. It will allow more than 200,000 uninsured state residents to receive government help to access health coverage (Krauskopf, 9/27). 

The Wall Street Journal: Arkansas To Use Medicaid Funds To Expand Private Coverage 
The Obama administration gave Arkansas the green light to use Medicaid funds in the federal health law to expand coverage through private insurance, a decision that could pave the way for at least six more states to opt in to a key provision of the law. Arkansas Gov. Mike Beebe, a Democrat, said he received a telephone call from U.S. Health and Human Services Secretary Kathleen Sebelius on Friday morning telling him she was approving the state's request to sign up about 218,000 Arkansans for private coverage (Radnofsky, 9/27).

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States Prepare For Medicaid Coverage Changes -- Even Those Not Expanding

States grapple with Medicaid expansion issues -- even in states like South Carolina that aren't using the health law's provision to expand coverage. In Texas, 1 million people may fall into a Medicaid "doughnut hole," and Ohio Gov. John Kasich waits to see how his push for expansion will affect his re-election chances.

The State: Medicaid Rolls Could Swell In SC, Even As State Eschews Expansion In Health Care Reform 
When the tidal wave of new health insurance customers begins to build in October, a large secondary wave is expected to hit state Medicaid agencies, even in states such as South Carolina that turned down Medicaid expansion. Tens of thousands of people required by provisions of the Affordable Care Act to get into the insurance market in 2014 will discover they are eligible for Medicaid benefits for which they've never applied (Holleman, 9/29). 

Fort Worth Star-Telegram: Medicaid 'Doughnut Hole' Leaves Many Working Poor Without Health Care Subsidies 
The Affordable Care Act ... will create another unintended gap in health insurance for residents of Texas and other states that did not expand Medicaid. Residents in this new "doughnut hole" make too much money to qualify for Medicaid but too little to qualify for subsidies on insurance bought through the state's federally run Health Insurance Marketplace, more commonly called the exchange. At least 1 million Texas residents will fall into that gap, said Stacey Pogue, senior policy analyst at the Center for Public Policy Priorities, an Austin-based organization that supports expanded public medical coverage (Fuquay, 9/28).

Columbus Dispatch: Medicaid Push Hurts Gov. Kasich With Tea Party 
Kasich is pushing to expand Ohio's Medicaid program to cover 275,000 more poor people with federal dollars provided under Obamacare. It's a deal-breaker for many tea party conservatives, but the question that might not be answered until November 2014 is whether it's a re-election breaker for Kasich. ... [T]ea party leaders -- namely Tom Zawistowski, who organized yesterday’s daylong convention -- have been threatening for months to find a way to beat Kasich (Vardon, 9/29). 

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Polls Show Continued Confusion Over Health Law

New surveys show public confusion persists over many health law provisions, including the role of health insurance exchanges which open for enrollment Tuesday, and the financial assistance that will be available to many people to help them buy coverage.

The New York Times: Survey Shows Confusion Over Health Care Law But Support For Medicaid Expansion
A day before the new health care exchanges open across the country, a new report shows that the more people understand it, the more they're inclined to participate. But while most people are aware of the law's requirement to buy insurance or face a penalty, a much smaller number have any understanding of the insurance exchanges opening on Tuesday or of the financial aid available to help people buy insurance (Bornemeier, 9/30).

Politico: Poll: Most Will Get Health Insurance
Asked whether they plan to get insurance when the requirement takes effect or pay the fine for not doing so, 65 percent of uninsured Americans said they would get health insurance, according to a Gallup poll out Monday. Twenty-five percent said they would pay the fine. Gallup also asked about the whether those individuals planned to use the exchange markets that launch Tuesday to buy their insurance. Almost half, 48 percent, said they planned to use the exchanges, 36 said they did not and 17 percent weren’t sure (Kopan, 9/30).

Kaiser Health News: Capsules: Poll Finds Most Unaware of Tuesday Opening of Health Insurance Marketplaces
A new poll finds a majority of the public -- especially those lacking health coverage -- is unaware that new insurance marketplaces created by the health law are slated to open this week. The poll also found deep skepticism of media coverage of the law, with more than half the public saying they don’t trust any media source to provide credible information (Rau, 9/29).

NBC News: 'Really Confused': Kaiser/NBC Poll Finds Americans Angsting Over Health Care Law
Americans remain deeply divided on the Affordable Health Care Act, with half confused about how it works or worried about how much it will cost them, a new poll shows. Just over half said they were worried, while slightly less said they were confused. Twenty-nine percent said they were angry about the ACA, compared to just 24 percent who described themselves as enthusiastic (Connor, 9/30).

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Despite Objections To Health Law, Insurers Work Hard To Make It Succeed

The Wall Street Journal looks at how these critics of the law are key to making it work. Also, Politico examines how large and small businesses are affected by Obamacare changes.

The Wall Street Journal: Key Groups Have Love-Hate Relationship With Health Law
Health-insurance companies spent more than $80 million trying to defeat President Barack Obama's health-care plan. Having failed, they have spent the years since trying to kill a string of provisions they don't like. And yet, it is those same insurance companies that are working harder than just about anyone to try to make the law succeed. It is one of the paradoxes of the sweeping health-care law: Fierce critics can also act as supporters who are key to whether the law will work. With Mr. Obama's struggles in selling the law, their efforts have become even more critical to its success (Meckler and Radnofsky, 9/28).

In other news about the image and selling of the law -

The Associated Press: FACT CHECK: Slippery Salesmanship From Obama On Health Care, Dubious Counterclaims From GOP
President Barack Obama is the insurance industry's most powerful pitchman these days as he drums up interest in the health insurance markets opening for business Tuesday. Whatever the merits of his product, there are reasons for the buyer to beware of his rhetoric. The president is being a bit slippery on the costs of coverage, in particular. His opponents are taking their own liberties as they talk up the ills of what they deride as "Obamacare" and defend their approach to the budget impasse that threatens to close parts of the government come Tuesday. On these points, caveat emptor (Woodward, 9/29).

Politico: Can The Media Avoid Rush Judgment On Obamacare?
When Obamacare enrollment begins on Tuesday, reporters in the Twitter age will be tempted to declare the health law a success or a failure in the first few days -- a judgment that will certainly be stoked by advocates on both sides of the issue. And any rush [to] judgments could have a big impact on public opinion of the law (Gold and Cheney, 9/28).

Los Angeles Times: Selling Obamacare: White House Touts Health Law In Women's Magazines
The current Cosmopolitan magazine explains the Affordable Care Act with the "Top Eight Ways Young Women Benefit from Obamacare." Glamour lays out the "Five Things You Need to Know" about the marketplaces kicking into gear Tuesday. The other night, late-night TV host Conan O'Brien put his own spin on the meme with "Ten Pre-existing Conditions to Drive Your Man Crazy" (Parsons, 9/30).

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Health Care Marketplace

Open-Enrollment, Obamacare Seasons Bring Employer Health Coverage Changes

The New York Times examines trends in this year's insurance open-enrollment season while Politico looks at what coverage requirements employers can expect from the health law. In the meantime, insurers are wary of covering some intensive psychiatric care and employer health coverage choices move to private insurance exchanges.

The New York Times: Trends To Watch For In Employer Health Plans
A lot of attention has been given to the health insurance exchanges opening next month. But if you're like most Americans, you'll still get your insurance through an employer. And that means the annual open enrollment season, when you choose your benefits for the coming year, will soon be upon you. ... Here are some questions to consider this year (Carrns, 9/27).

Politico: How Obamacare Affects Businesses – Large And Small
When Congress was writing Obamacare, its biggest backers said the new law would help small businesses. Instead, they’re complaining about it. It was also supposed to take the cost pressure off businesses in general. Instead, they say it’s just adding more pressure. It’s one of the biggest political ironies of the health care law: Some of the loudest gripes are coming from the employers who were meant to benefit from it. But the reality is, from the smallest startups to the largest corporations, employers have a lot of new rules and reporting requirements to keep track of. And in some cases, there are new costs, too. It’s the only way to make the law work — but it’s also a headache for many employers (Nather, 9/30).

The New York Times: Lacking Rules, Insurers Balk at Paying For Intensive Psychiatric Care
Patients often find themselves at odds with health insurers, but the battles are perhaps nowhere so heated as with the treatment of serious mental illness. It was not supposed to be this way. A federal law, the Mental Health Parity and Addiction Equity Act of 2008, was aimed at avoiding fights like this over coverage by making sure insurers would cover mental illnesses just as they cover treatment for diseases like cancer or multiple sclerosis. ... But five years after President George W. Bush signed the law, there is widespread agreement that it has fallen short of its goal of creating parity for mental health coverage. As enrollment in coverage under the Affordable Care Act becomes available on Tuesday, the rules underlying mental health coverage in general -- for both private insurers and the new health care exchanges -- are still unclear, mental-health patient advocates say, leaving patients and families to grind through the process as best they can (Abelson, 9/28).

St. Louis Post-Dispatch: Employee Health Coverage Moves To Private Exchanges
If you work for a pretty big company, there’s a reasonable chance that sooner or later you’ll be choosing your health coverage and other benefits through a private exchange. It’s a growing trend in employee health insurance, and it has good and bad aspects for workers (Gallagher, 9/29).

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State Watch

State Highlights: Calif.'s Drug Medi-Cal Program Probed

A selection of health policy stories from California and Texas.

Los Angeles Times: Gov. Brown Signs 2 Of 3 Bills Fighting Prescription Drug Abuse 
Gov. Jerry Brown signed two bills Friday aimed at curbing prescription drug abuse but vetoed a third that could have helped the state's medical board identify reckless doctors whose patients died on pills they prescribed (Glover and Girion, 9/27).

The New York Times: Rights Groups And Clinics Sue Texas Over Provisions In Its New Abortion Law
National women’s rights groups and Texas abortion clinics filed suit on Friday in federal court in Texas, seeking to block provisions of a new state law that they said would have "dramatic and draconian effects" on women’s access to the procedure (Eckholm, 9/27).

California Healthline: DHCS Director Apologizes At Hearing Examining Medi-Cal Drug Program Fraud
Department of Health Care Services director Toby Douglas apologized for "lapses in state oversight" of a Medi-Cal drug abuse treatment program at a hearing yesterday in Sacramento. … Yesterday's joint legislative oversight hearing was convened to address allegations of fraud and Medi-Cal system abuse within the Drug Medi-Cal program, which is overseen by DHCS. Reports by the Center for Investigative Reporting and CNN said rampant and persistent fraud went relatively untouched by state oversight (Gorn, 9/27).

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Editorials and Opinions

Comments On Shutdown: Both Parties Are Shirking Their Duties; This Fight May Hold Off Health Law Battle On Debt Ceiling

The Washington Post: U.S. Congress's Dereliction Of Leadership On Government Shutdown
Yes, defaulting on the U.S. debt would be worse than shutting down the government. But both represent such recklessly, breathtakingly, wastefully irresponsible derelictions of leadership that the people who run this town ought to be ashamed of themselves if either comes to pass. Moreover, we are not reassured by the argument that a shutdown would make a default, which could come in mid-October, less likely. As the habits of normal compromise and negotiation become ever more frayed, further deterioration strikes us as at least an equally plausible alternative to the hoped-for wake-up call that shocks the capital back to common sense (9/29).

The New York Times: The House Rushes To A Shutdown
Delaying the health law by a year, supported by all but two House Republicans, would prevent 11 million uninsured people from getting coverage in 2014 and raise premiums for those buying coverage in the individual insurance market. The real goal is not to delay but to destroy health reform by making it appear unworkable. ... Repealing the tax on medical devices, supported by all House Republicans, would add $30 billion to the deficit over 10 years and reduce the revenues needed to pay for coverage for low-income people. This vote was nothing but a capitulation to the medical device industry and its lobbyists. ... The House even included in its spending bill a provision allowing employers to opt out of covering women's preventive health care, including contraception (9/29).

The Washington Post: The House GOP's Shutdown Plan Is Great News
Speaker Boehner's original plan was to pass a clean bill to fund the government and then attach the one-year delay of Obamacare to the debt-ceiling bill. It was a strategy that would minimize the chances of a shutdown but maximize the chances of a default. Boehner wanted that strategy because he thought Republicans had more leverage on the debt limit than they do on the shutdown. A shutdown, after all, is just bad for the economy. A default is catastrophic for it. You'd have to be insanely reckless to permit the federal government to default on its debts. And Boehner believes that House Republicans are insanely reckless and that President Obama isn't. But that strategy failed. Boehner's members refused to wait for the debt ceiling. They want their showdown now. And that's all for the better (Ezra Klein, 9/29).

The Wall Street Journal: An Obama-Cruz Shutdown
We've criticized GOP Senator Ted Cruz for his strategy to make defunding Obamacare a requirement of funding the rest of government. He and his allies know that Mr. Obama can never agree to that, and even millions of Americans who oppose Obamacare don't agree with his shutdown ultimatum. It risks political damage for the House and Senate GOP in 2014 even as Mr. Cruz builds his email list for 2016. Yet it takes two to tangle, and Mr. Obama is as much to blame for the partisan pileup as Mr. Cruz. This is a President who is eager to negotiate with dubiously elected Iranian mullahs but can't abide compromise with duly elected leaders of Congress (9/30).

Reuters: Ted Cruz: Blackmailer
Cruz's tactics are the problem. He and his allies are holding the federal budget hostage. If they don't get their way, they're threatening to shut down the federal government. That angers Cruz's fellow Republicans — who fear they will get the blame for a government shutdown as they did in 1995. Meanwhile, Obamacare will still be law. Cruz's colleagues see the effort as futile and self-serving, damaging the Republican brand in order to advance Cruz's 2016 presidential prospects with conservatives. Cruz has returned fire, blasting his critics as "defeatists" who belong to the "surrender caucus" (Bill Schneider, 9/27).

Bloomberg: Obama Should Make One Demand Of Republicans
Obama's first goal should be to take the weapon away from his opponents. If he can deliver reasonable, and for Boehner, face-saving, concessions (the delay of the Affordable Care Act isn’t one) in return for a permanent moratorium on debt-ceiling threats, the long-term benefit to his successors -- Republicans and Democrats alike -- is worth the immediate sacrifice. This may not be possible. House leaders have ratcheted up their rhetoric and the expectations of their caucus to the point that many Tea Party Republicans appear convinced that they can reverse the implementation of a landmark law by minority fiat (9/29).

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Viewpoints: Health Law Rollout Brings Excitement And Concerns; New Disparities Likely In States Turning Their Back On The Law; Is The Coverage Affordable?

The New York Times: Dawn Of A Revolution In Health Care
The United States is embarking on a truly historic journey toward near-universal health care coverage this week. Starting Tuesday, the federal government will make it possible for millions of uninsured Americans who can't get health insurance, or can't afford it, to obtain coverage with the aid of government subsidies. It is a striking example of what government can do to help people in trouble (9/28). 

Los Angeles Times: Finally, The Obamacare Rollout
State insurance-buying exchanges — one of the centerpieces of President Obama's controversial 2010 healthcare law — begin their first open enrollment period Tuesday, an event that both supporters and opponents have been eagerly anticipating practically since the legislation was signed 3 1/2 years ago. For the first time, low- and moderate-income Americans who don't have health benefits at work will be able to sign up for comprehensive coverage at a discount, thanks to taxpayer subsidies that offset much of the costs (9/30).

The Wall Street Journal: Obamacare Arrives
The Affordable Care Act opens for business on Tuesday, a testament to liberal perseverance if not wisdom. The plan was dragged across the finish line in 2010 with only Democratic votes but no democratic consensus, and then survived a wave election, an historic constitutional challenge, the 2012 campaign and durable popular opposition. This half-decade political debate has also been a period of convulsive change for the one-sixth of the economy that the law is supposed to "reform." So ObamaCare's start is a moment to step back from the day-to-day Washington scrum and take stock of American health care as this liberal vision unfolds (9/30).

The New York Times: Is Health Care Reform Creating More Part-Time Work?
Republican critics of the Affordable Care Act often argue that the reform law has caused a big uptick in the number of part-time workers. The A.C.A. requires companies with 50 or more employees to provide health insurance to those working 30 hours or more a week, or pay a penalty. ... But neither the facts nor logic support [the Republicans'] claim. The recession, not the A.C.A., caused the increase in part-time work, which — besides — largely occurred before the reform law was enacted (Philip M. Boffey, 9/27).

The New York Times: Birth Control And A Boss's Religious Views
The Obama administration's rule requiring employer health plans to cover birth control without a co-payment has given rise to a slew of lawsuits by private companies claiming the mandate attacks religious freedom. Three federal appeals courts have ruled on the issue, with two correctly rejecting that view as without legal foundation. Given the conflicting rulings, it is a good bet the Supreme Court will agree to address this issue in the next term (9/29).

The Washington Post: How The Obamacare Fight Could Create New Health Disparities
Obamacare certainly will increase access to health care across racial and class lines. Yet the program's success relies on the cooperation of two dozen conservative-leaning states that are home to half of the nation’s 50 million uninsured. In many of these states, the public tends to oppose the law, and politicians are doing all they can to undermine it. If they succeed, the dawn of the Affordable Care Act may create new disparities in health coverage between the states that embrace Obamacare and those that resist it (Zachary Goldfarb, 9/27). 

The New York Times: 'Affordable Care' Or A Rip-Off?
As Americans begin signing up this week to buy insurance, they will begin to test the legislation's tantalizing promise to make health financially viable. Will the policies deliver care at manageable prices, or will "affordable" seem like a hollow promotion? That probably depends a lot on patients' needs, where they live and — importantly — their preconceptions of what health insurance is supposed to do, experts say (Elisabeth Rosenthal, 9/28). 

Reuters: Obamacare's Threat To Healthcare Innovation
The Obama administration is now characterizing October 1st as the beginning of a "soft launch," during which federal and state officials will work out various kinks. And though this might sound like just another bureaucratic foul-up, the success of the exchanges in these first few months will have enormous implications for the ultimate success of Obamacare (Reihan Salam, 9/27).

Politico: Despite Claims, Obamacare Gives Congress No Special Treatment
Some health reform opponents claim the Obama administration is giving members of Congress and their staffs special treatment under the Affordable Care Act. The claim, which a number of media stories have repeated uncritically, is simply false: Although they will be required to enroll in health plans offered within the new health-insurance exchanges established under the law, members of Congress and their staffs will not receive extra financial help to pay for their medical care (Robert Greenstein, 9/29).

USA Today: Obamacare Vs. Affordable Care Act
A recent CNBC poll found more Americans oppose Obamacare than oppose the Affordable Care Act. But more Americans support Obamacare than the Affordable Care Act. Confused? That would be understandable given that these are two names for the same law (Jonah Goldberg, 9/29).

St. Louis Beacon: Obamacare: Less Choice, Higher Taxes, Slower Economic Growth
The time for enrolling in health exchanges is now upon us. Recent polls show that the majority of Americans continue to disapprove of the health care law — the Affordable Care Act, commonly referred to as Obamacare — enacted in 2010. But how many of us really understand what we can expect and what we will pay for this "affordable" health program? The simple fact is that most of us are just plain bewildered, not knowing how the controversial law will affect us (R.W. Hafer, 9/30).

DesMoines Register: Arrival Of Affordable Care Act Is Good News
Though Obamacare is complicated, the most important aspect of the law is simple: Americans will finally be able to buy insurance regardless of their health history or employment status. Premiums for coverage in new insurance exchanges will be based on age, smoking and where an applicant lives. An Iowan cannot be denied coverage, charged more because he has diabetes or excluded from certain benefits because he incurred a back injury 20 years earlier (9/29).

Reuters: The Flimflam Of This Week' Obamacare Numbers
At midweek, the Department of Health and Human Services released its report on the health plan choices and insurance premiums available under the Affordable Care Act, which opens for enrollment on Oct. 1 in 36 states. … The reporters who filed squishy reports, or led with squish, are only partly to blame. According to Politico, the HHS distributed the report to reporters under embargo — which essentially places blinders over their eyes, plugs in their ears, and socks in their mouths (Jack Shafer, 9/27).

Salt Lake Tribune: Time To Stop Dithering And Expand Medicaid In Utah
When both a warm heart and a cold calculation lead to the same conclusion, a desire to do something different can require a great deal of rationalizing. Such thinking was on display in large measure Thursday when Gov. Gary Herbert hosted a his annual day-long Health Summit in Salt Lake City. Much of the program was devoted to trotting out alternatives to the best next step in health care reform, the one that would help low-income people and save the state millions of dollars. That step would be the full expansion of Medicaid under the provisions of the Affordable Care Act (9/28).

Bloomberg: A National Family-Leave Law? It’s A Start
Democrats are about to try, and almost certainly fail, to secure paid parental and family leave for most American workers. That could still be an achievement, if it starts a conversation about how to provide American workers with the flexibility they need to manage family needs (9/27).

Bloomberg: Worried About Cancer? Get Married
Controlling for demographic factors such as age, race, education and household income, researchers who analyzed records of more than 730,000 cancer patients found that married patients did significantly better than single people. They lived longer, received better treatment and were more likely to be diagnosed before metastatic cancers developed. ... "The most likely reason," the authors conclude, "is that married patients have better adherence with prescribed treatments than unmarried patients." They have someone to watch over them (Virginia Postrel, 9/29).

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Stephanie Stapleton

Andrew Villegas

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Shefali Luthra

The Kaiser Daily Health Policy Report is published by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. (c) 2014 Kaiser Health News. All rights reserved.