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Health Insurance

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Karen Pollitz
Research Professor, Georgetown University Health Policy Institute
Wednesday, October 17, 2007; 12:30 PM

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Karen Pollitz: Hello and welcome to the Washington Post online discussion about health insurance. I'm Karen Pollitz, a research professor at Georgetown University, and I'm happy to participate in this discussion. I'll try to answer as many of your questions as I can in the hour that we have. This is an important topic. Navigating health insurance changes can sometimes be complicated and confusing. For more general information, please also see health insurance consumer guides that my Georgetown colleagues and I have developed. They're free to the public online at www.healthinsuranceinfo.net.

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Washington, DC: Hi. I am a self-employed artist with an individual Carefirst plan. I also have a strong family history of breast cancer and am considered high risk (currently getting heightened screening). I was wondering what would happen if I move to another state. Would I likely be denied coverage and/or is my Carefirst policy portable? Thanks, Betsy.

Karen Pollitz: Your CareFirst policy is not necessarily portable. My understanding is that some Blues plans will accept transfers from other states, but you can't count on that.

In most states, your ability to buy insurance on your own (outside of a job-based plan) is highly dependent on your health status. But in a few, such as NY, insurers cannot take your health status into account when they decide whether to issue coverage or how much to charge. To learn more about your health insurance protections in other states, see Georgetown's consumer guides at www.healthinsuranceinfo.net.

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Washington, DC: For people over 50 that buy their own health insurance, my experience is that it is difficult to change plans (even if your claims history is pretty good). At times, I feel like the health insurance industry is treating me like a hot potato that nobody really wants to get stuck with. I am in excellent health, but sense the industry labels me as high risk because of my age. What advice can you give to older Americans that do not yet qualify for Medicare, but are concerned about health insurance premiums that are going out of sight?

Karen Pollitz: Your hot potato analogy is a good one. Most individual health insurance is 'age-rated' meaning premiums go up with each birthday. With most insurers, the impact of age rating isn't too burdensome before age 50, but after that age, premiums start to increase pretty dramatically. Unfortunately, in DC, you don't have many protections in this market. Some people consider drastic changes -- such as moving to another state, or returning to work for an employer that offers health benefits.

It's also helpful to share your story. Staying insured shouldn't be this hard. Let your elected officials know what's happening and that you want access to coverage that is affordable and adequate.

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Fairfax: Where do I begin to look for health insurance? Unemployed, age 60, healthy, uninsured, divorced. No Cobra available.

Karen Pollitz: Sounds like the individual market is the coverage source available to you. You can check with an insurance broker. Many companies also offer quotes on line. You'll have to submit to medical underwriting -- answer questions about your current health status and health history. Depending on your answers, getting coverage may be straightforward or difficult. Insurers can be pretty picky about who they cover.

Also, as I noted in an earlier answer, the individual market is age rated, so premiums at age 60 are likely to be pretty high, even if you're in perfect health.

You said you're unemployed. If you do find work with job benefits, that may turn out to be a better source of coverage. Job based health benefits tend to be more comprehensive than what you can buy on your own, and employers usually pay most of the premium on your behalf. In addition, you have more legal protections against discrimination in job-based coverage.

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Fredericksburg, Va.: What are the best options for a 23-year-old student with pre-existing conditions including bipolar disorder and a recent ankle surgery? She will shortly no longer be covered by our insurance as a dependent.

Karen Pollitz: Your best option may be COBRA coverage. If your daughter is covered under your job-based plan and the employer employs at least 20 workers, she will be eligible for COBRA continuation coverage once her eligibility for dependent coverage expires. She can remain covered under COBRA for up to 36 months. She will be responsible for paying the entire premium for a single individual. Your employer is not required to subsidize her premium under COBRA (though you can help her out.)

Her other option would be to try to buy an individual policy. However, given her pre-existing conditions, she may have trouble doing so.

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Baltimore: By way of introduction: I take home about $24K after taxes ($40K gross) each year. Not a homeowner, late 50s, single female. With rent costs so high, utilities going higher, and even the recent rise in the cost of food (bought lettuce recently?), I am struggling with health insurance options (or rather lack of). My small employer doesn't offer health insurance to me, I was turned down for coverage due to my BMI (36.5), and have had health issues, none recent though. Question: What is a reasonable amount for someone in my position to pay for health insurance. I certainly don't feel I have that much leeway in my budget right now; I mean when does my life become working to pay bills and basic existence? It's not like I'm extravagent -- last vacation was three years ago for five days. Do I stop buying groceries (so my BMI comes down:). How much should I have to pay on top of every other living expense? $200 a month would really impact me. $300 is just out of the question. Any ideas?

Karen Pollitz: You may want to look into the Maryland Health Insurance Plan (MHIP) See their web site at http://www.marylandhealthinsuranceplan.net/.

This is insurance sponsored by the state of Maryland. It's expressly for people, like yourself, who have been turned down by private insurers. You pay a premium for coverage, there is a deductible, etc., just like private insurance. The benefits are pretty comprehensive. Other states run similar programs, though I think Maryland's is one of the best in the country.

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Sarasota, Fla.: I am presently on COBRA. I have a pre-existing condition, metastatic breast cancer which requires a lot of medication. I do not qualify for disability, since the metastisis is not in a remote location. It is my understanding that I have no options other than to quit my present job, find another with a health plan to maintain health insurance when COBRA expires on April 1. Is that correct?

Karen Pollitz: You will be HIPAA eligible when your COBRA expires. In Florida, however, that may not offer you much protection. Insurers in the individual market will not be allowed to turn you down or exclude coverage for your pre-existing condition. However, there's no limit on what they can charge and premiums are likely to be very high.

If moving is a possibility, you can obtain coverage in other states during the 63-day window that you'll be HIPAA eligible.

For more information about HIPAA in Florida and other states, go to www.healthinsuranceinfo.net.

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Miami: What can you do to your insurance company to lower your health insurance premium?

Karen Pollitz: Not much. You can ask the company to increase your deductible. But this means if you do get sick, you'll have to pay more of the bill out of pocket. Also, many insurers won't let you later reduce your deductible unless you reapply and re-submit to medical underwriting.

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Philadelphia: Why do insurers deny coverage to expectant fathers, even -- as in my case -- when the expectant mother is already covered under a separate plan? Are new babies a grievous health risk to fathers? Or are the insurance companies worried about incurring some sort of obligation to cover the child after it is born?

Karen Pollitz: Interesting. I knew insurers always deny coverage to pregnant women. Didn't realize dad's got the same treatment. You did answer your own question correctly. The insurer is worried you'll transfer the child to your policy after s/he is born. The insurer would prefer to wait until the baby is born and be certain there are no complications or disabilities before agreeing to cover the child.

I wish you all the best!

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23-year-old Freelancer: I am a 23-year-old freelancer, making about $43K a year but completely uninsured. I am healthy though...I don't need to be on medicines, etc., so (so far) it has worked out okay. My girlfriend keeps bugging me to buy insurance...any advice on the best plan for me that provides basic coverage but is as cheap as possible?Thanks!

Karen Pollitz: Good for your girlfriend!

There's a lot of cheap insurance out there. Be careful what you buy. Often, cheap means flimsy. Remember you are buying coverage in case you get sick, not in case you stay healthy.

Look for the most comprehensive benefits you can find. Rx coverage is important. You may not be taking anything now but if you get seriously sick, prescription drugs are very expensive.

Also, keep an eye on the out-of-pocket maximum. This is the amount of cost-sharing (copays and coinsurance and deductibles) you'll be required to pay for covered benefits. After you reach the maximum, the policy will usually pay 100% of covered services for the remainder of the year.

Watch for exclusions. Some policies simply won't cover services such as mental health care, rehab services or other care that could turn out to be important to you.

And watch for other limits on covered benefits. There are policies that only cover four office visits per year (again, fine for you now, but not if you get cancer!), only a few days in the hospital, only $1,000 worth of prescriptions.

Good luck to you.

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Get Gap Coverage! : My husband and I had to get gap coverage for two months last year. We relocated and I was not working and his new insurance had not kicked in. It was great -- about $50 a month for each of us ($100 total) and it kept me from worrying about a $120K hospital bill if one of us was in a terrible accident. We considered COBRA through the huge Fortune 100 company that we left but it was going to be $700 a month for both of us. At our ages, it would have been over-insurance. People put down short term coverage -- they shouldn't -- it is not so bad!

Karen Pollitz: A lot of people do consider and purchase gap coverage (also known as short-term policies). Typically these policies provide coverage for only a few months. You can renew them, but only at the insurer's option. I'm glad it worked well for you. But these policies are risky unless you absolutely know your next coverage will be there for you. For example, had your husband's coverage not "kicked in" -- say he became seriously injured and had to quit work from the job that had promised future health benefits - the insurer would have refused to renew your gap policy when its term expired. If he had had continuing care needs at that point, he'd have been uninsured and uninsurable.

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Burke, Va.: My insurance company (Aetna) tells me that I am not covered for my pre-existing condition (even though I am paying a 25 percent premium to be covered for it) because I was not insured by another company within 63 days of my start date on their policy. Is this enforceable or legal? How is it possible to get a decision on "pre-existing conditions" question from a health insurance company? My current problem is not related to my pre-existing condition.

Thanks, Steve.

Karen Pollitz: In Virginia, the insurer may not be required to credit your prior coverage against the pre-ex exclusion period if you had a gap in coverage of more than 63 days before this policy took effect. You may want to call the Virginia Bureau of Insurance, however. Explain your situation and see if they can be of any help. A link to the Bureau can be found in the Virginia consumer guide at www.healthinsuranceinfo.net.

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Fort Washington, Md. I am a pre-retiree with health issues. Upon retirement, I will become a medicade/medicare candidate. Is there affordable insurance available for retirees who are receiving a fixed income?

Karen Pollitz: You, too, may want to look into the Maryland Health Insurance Plan (MHIP). This state program sells coverage to residents who would have trouble purchasing it from private insurers due to health conditions. MHIP also offers discounted premiums for people with modest incomes.

For more information, see http://www.marylandhealthinsuranceplan.net/.

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Baltimore: Followup to your MDHIP referral. Sure, I can be insured for $179 per month, close to my $200 limit. Of course, I'd have to foot the first $2,600 of expenses myself under that coverage, which then adds another $200 per month, for $400 per month average for medical care. On my income, not possible, unless I choose insurance over a reasonable life. That's what my question really is about. What is a reasonable sacrifice for medical insurance for someone. Somehow, taking one-sixth of my take home salary for insurance doesn't seem like a great tradeoff.

Karen Pollitz: I see your point and agree, people should not be asked to choose between paying insurance premiums and rent.

MHIP does offer discounted premiums for people with limited incomes. At the Web site, look for information on MHIP+ In the top left corner of the screen, click on "About the plan" and then choose the link to the MHIP+ application.

Depending on your income, you may get the same or lower premium for a better policy with a lower deductible.

Good luck!

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Pasadena, Calif.: I often hear critism of a single payor system, but don't really understand how that is different from a Medicare like system extended to everyone. Medicare seems to get high marks from consumers and from the healthcare providers, especially when some form of drug coverage and a supplemental policy. What is a single payor plan and how is that different from the Medicare model? Thank you for this timely topic.

Karen Pollitz: Single payer refers to a single federal government health program. Medicare is a single payer model for covering senior citizens in the United States. In theory, Congress could create a different federal program for Americans under the age of 65. That program could also be a single payer, but provide different benefits, charge different premiums, pay different fees to doctors and hospitals, etc. There's nothing magic about single. But people do seem to have strongly different feelings about the concept. Some fear a one-size-fits-all insurance program. Some worry it will lead to greater government intrusion in the delivery of health care. Others think it would be more equitable, more efficient, and less complicated. The devil is in the details, I suppose. But for the past 40-plus years, Medicare has worked pretty well for senior citizens (and disabled persons under the age of 65 who qualify, as well.)

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Cedar Grove, N.M.: What are the best resources for consumers shopping for health insurance? I was recently looking for insurance, but could not find a source of information that did not also want to sell me an insurance plan.

Karen Pollitz: Try our consumer guides at www.healthinsuranceinfo.net.

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Alexandria: Hi Karen,

I am a federal worker and need to pick an insurance policy for me and my husband. Which one of the options is the best option to carry into retirement? We are healthy early 50s, and plan to work for another five years. We do not mind higher deductions as long as we are covered for our perscriptions, and most of our of our health care needs especially catestrophic health coverage.

Karen Pollitz: With the FEHBP, you have the option of changing plans annually at open season. Given that, you may want to elect one of the less expensive plans that provides less coverage or requires a higher annual deductible. While you're healthy, this may suffice. If health changes down the road, you'll have the option of changing to a more comprehensive plan. However, the open season is offered only once per year. If your health declines in February, you'll have to wait 11 months before you can switch to better coverage.

Good luck!

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Chicago: What would happen to insurance companies if we got single-payer universal health care? I know some proposals incorporate the private plans into the system, but I'm wondering about a "Medicare for all" type system. Do the companies instantly go out of business? Would they be taken over by the government?

Karen Pollitz: It really depends on what the Congress enacts. Even if Congress were to extend Medicare to all Americans, there would likely be work for some insurance companies to help administer the program. Today, the federal government hires private insurers to process Medicare claims. Similarly, many large employers today do not "buy" health insurance. Instead, they pay claims with company funds and merely hire an insurer to process the claims.

So it is likely there would be a big job for at least some insurers to help administer a single payer system.

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Dumfries, Va.: If I already have insurance but need something that is not covered, may I qualify for Medicare part B?

Karen Pollitz: You generally are eligible to enroll in Medicare Part B when you turn 65. Some people may be eligible earlier if they become disabled or their kidneys fail. For more information about medicare eligibility, go to www.medicare.gov.

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Norwich, Conn.: Hi Karen,I am 49, have individual coverage through Golden Rule and my rates have risen dramatically since I became insured with them approximately two years ago. I have never submitted a claim. (It is a high deductible policy.) Pacificare offers new insureds significantly lower premiums and lower deductibles for similarly situated people. But they claim such coverage is not available to me as I am locked into the pool of insureds when I originally signed up. Is this legal? Is there anything I can do? (It seems completely unfair to lock me in to a pool but offer better and cheaper coverage to new insureds.) Any thoughts or help you can offer will be greatly appreciated.

Karen Pollitz: Check with the Connecticut insurance department. Contact information in our Connecticut consumer guide at www.healthinsuranceinfo.net.

I think Golden Rule and Pacificare may now both be owned by the same company (United Health Care), but I was not aware that they could refuse to allow you to switch among their policies. The Connecticut regulators would be the authority on that question. Meanwhile, if you're healthy, you could also look at other carriers, such as the Blues.

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Regional costs: The past year I was able to use CareFirst to cover an out of college daughter in MD. Then she moved to Hartford, CT and needed a new plan. All the Blue Cross plans were over double and did not have as good a coverage. Do health insurance plans really vary that much from state to state?

Karen Pollitz: Yes, they vary enormously!

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Seattle, Wash.: What's your take on medical savings plans that are offered as an alternate to insurance? They 'seem' good, but I don't know how to evaluate them...

Karen Pollitz: What do you mean by "medical savings plans?" Are you referring to discount plans? If so, I would advise you to stay away from those. They are not a substitute for insurance.

Or are you referring to medical savings accounts that can be combined with high-deductible health insurance policies? High deductible policies are a different type of insurance, not an alternative to insurance. If you think you could afford to pay out of pocket for care that is subject to the deductible, this might be a reasonable alternative for you. Just be sure to read the policy carefully. In addition to the deductible, you'll want to be familiar with other cost sharing requirements, the out of pocket maximum, what services are covered or excluded, and so on.

Buying inadequate insurance can be dangerous. Remember, most bankruptcies in the United States are due to high medical bills and the majority of people who filed for that reason had health insurance. The average level of medical debt that bankrupted people was under $14,000.

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Anonymous: We have a child who was diagnosed with Pervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS), which is a diagnosis on the autistic spectrum. We have health insurance now, provided by my husband's employer, but he's thinking about moving into a job where he would be self-employed, thus we'd be purchasing a family plan from one of the regional providers. My question is: is autism considered a pre-existing condition? Could we possibly all be denied coverage because of our child's diagnosis? How could we find out what their policies are before we make major career decisions?

Karen Pollitz: Your child's condition would likely be considered pre-existing. In the individual market in most states, you might not be able to add your child to your family policy. Check our consumer guides for the state in which you live: www.healthinsuranceinfo.net. If you live in a state where individual market coverage is guaranteed issue and community rated and where insurers must credit prior coverage against any pre-existing condition exclusion period, you may be ok.

Also know that your family will be eligible for 18 months of COBRA coverage if your husband leaves. That may provide a bridge to help you explore your options.

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re: "I am healthy though...I don't need to be on medicines, etc., ": Me too. Then I fell, shattered my elbow, dislocated my elbow and tore my ligaments. Without insurance I would have paid $45,000 plus. You HAVE to be prepared for a catastrophy.

Karen Pollitz: Amen!

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Georgetown: Hi Karen,I'm a former student of yours at GPPI and just wanted to say I still think you're doing great work and it's great to see you on this chat. My question to you is, which of the 2008 presidential candidates' plans have promise for truly providing coverage to the uninsured (if any)? Also, if you have contact information I'd love to drop a line and say hello.

Karen Pollitz: Hi yourself! Thanks for your kind words. You didn't sign your name, but it's always a treat for me to hear from former students. I'm at the same place. Call me directly or through GPPI!

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confused: I thought as long as I had current coverage that no insurer for which I am otherwise eligible could deny me or otherwise refuse to insure me -- is this not true?

Karen Pollitz: No, it's not true.

On average, over a three year period, about one in four adults seek individual health insurance (and most have trouble obtaining it). People need to buy coverage on their own if they lose eligibility for job-based coverage and they aren't eligible to be covered under public programs such as Medicare or Medicaid.

In most states, insurers in the individual market can and will refuse to sell you coverage if you have a serious health condition, or a history of serious illness, or even if you have a mild health condition such as hay fever or acne.

The individual market is small and most people don't need it most of the time. But we do change coverage, and for people in transition, the individual market can be the weak link in the health insurance chain.

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Adverse selection avoidance: I work at a hospital, so I have great medical insurance (the hospital admins understanding how important good insurance is), but in case I have to go out on the private market again, how can I avoid adverse selection by insurance companies related to my medical history? Specifically, I was overweight and Type II diabetic but have lost a ton of weight. How can I prevent insurance companies from using this to deny me policies or jack up the costs?

Karen Pollitz: You can't, really. Your health history is what it is and should you ever apply for an underwritten policy, you'll be asked to disclose it. Don't lie. Insurers usually find out and that can be grounds for rescinding coverage when they do.

What you can do is try your best to remain in protected coverage. Job-based health insurance is not allowed to discriminate based on your health status or health history. In some states, individual health insurers can't either.

Be careful, and good luck!

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Denver, Colo.: I am 56 years old and under COBRA. My spouse's company says that I am entitled to COBRA benefits for 48 months. The cost is fairly reasonable and the health care benefits are excellent. I am in excellent health have no prior health conditions. Should I stay with COBRA until it is exhausted or find a policy on my own while I have such excellent health?

Karen Pollitz: Wow, 48 months is a lot. Your spouse's company is being more generous than required by law. If the health benefits are excellent and you've got this unusually generous continuation benefit, you may want to hang on to it.

On the other hand, COBRA can be expensive. If you're in good health, you may be able to obtain an individual policy (though at age 56, the price differential may or may not be all that dramatic).

Shop around, but be careful to compare apples to apples. Cheaper policies often cost less because they cover less. At age 56 (I'm not there yet but I'm closing in...) many of us start to develop health issues. That's when we really appreciate what it means to have excellent health insurance coverage!

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Washington, D.C.: I haven't seen a doctor in over two years due to the fact that none of my employers have offered me health care, and I've never made enough to be able to afford it. I've staved off emergencies by buying antibiotics in Mexican pharmacies, being very careful and comforting myself with the knowledge that the tip of my finger WOULD eventually grow back. I'm leaving the country next year with a group who will pay my health care costs (go figure, I can get health care as soon as I leave the United States), but until then, I need to get myself checked out in order to be eligible for travel. I'm healthy, no real pre-existing conditions, female, and 24 years old. What options do I have for VERY CHEAP coverage (READ: Under $100) for a few months in order to get my check ups completed?

Karen Pollitz: If all you need is the check up, one option may be to just have it and pay the doctor directly.

You can shop online for policies and see if any will cover checkups. Most policies in the individual market that are inexpensive have very high deductibles ($1,000 or more) so if the policy covers check ups, you would have to pay for it out of pocket anyway.

If you are paying cash, you might ask the doctor whether s/he would discount the charge to the level that an insurance company or Medicare would pay. Sometimes doctors will do that as a courtesy for patients who don't have health insurance. Often, they will ask that you pay the bill in full at the time of service in order to qualify for the discount.

Good luck!

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NYC: My 26-year-old son worked in NYC for two years where he was covered by a comprehensive plan. When he left his job to return to school, also in NYC, we compared the cost of COBRA to individual insurance (his school, CCNY doesn't offer student insurance). COBRA is $396 a month. The cheapest individual insurance for a non-smoking 26-year-old male is $415 (checked on ehealthinsurance). Either of those is a lot of money for a student or his mother to pay. Are there alternatives in NY that we've overlooked? He's very healthy, but doesn't want to go uninsured. Thanks

Karen Pollitz: New York has a program called Healthy New York. It's subsidized, so less expensive, but the plans also provide fewer covered benefits.

You can find a link to HealthyNewYork on the NY Insurance Department web site http://www.ins.state.ny.us/chealth.htm.

There, they have other information about health insurance options and protections in that state.

Good luck.

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Karen Pollitz: Thanks everybody for your wonderful questions. Sorry I couldn't quite get to them all.

As this session indicates, health insurance is important. But it's not always available, affordable, and adequate for those who need it most. I hope that changes. Discussion forums like this help us remind us there is work to do. Thanks to the Post for covering health insurance issues. Keep up the great work!

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Editor's Note: washingtonpost.com moderators retain editorial control over Discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions. washingtonpost.com is not responsible for any content posted by third parties.


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