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But advocates question whether the plan will increase families’ access to health care, without limits on co-payments and deductibles.

The proposal involves Utah’s Premium Partnership for Health Insurance, or UPP, which now gives families up to $150 a month to help pay premiums for employer-sponsored health insurance – a kind of plan that is not available to everyone.

Starting in July 2009, the experiment would allow people enrolled in UPP to use the state subsidy to buy private health insurance. It would aim to provide health insurance coverage to 5,000 adults and 1,000 children – numbers included in the draft application but not yet final, said Medicaid director Michael Hales. The proposal is part of House Bill 133 – the state’s health system reform effort, which is centered on getting more Utahns on private insurance rolls.

Advocates for low-income families say the program may indeed reduce the ranks of the uninsured. But whether it succeeds in actually improving their access to health care is another question.

“The Legislature was trying to make a philosophical statement with HB133: ‘We want families in private health insurance,’ which is OK,” said Lincoln Nehring, the Utah Health Policy Project’s Medicaid policy director. “But I don’t think they really thought through the ramifications.”

Under the proposed changes to UPP, adults enrolled in the program would also have to enroll their children; their children would be blocked from the Children’s Health Insurance Program, or CHIP.

That’s a problem, Nehring said, since there are cost protections built into CHIP that don’t apply to UPP.  “There is not a limit on the out-of-pocket expenses they [UPP families] could potentially pay and that puts children at great risk,” he said.

Hales stressed that the proposal is only a working draft and that nothing is final. The proposal will be reviewed in July by the state’s Medical Care Advisory Committee, then sent to the Centers for Medicare and Medicaid Services (CMS) in coming months.

The “free market” of medicine is not free at all. It can’t be free when the there are more than 2 pharmaceutical lobbyists for every 1 member of Congress. It can’t be free when the pharmaceutical industry spends more than any other industry on its lobbying efforts. ($758 million since 1998 as of 2005)

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To be a smart patient, you can’t be passive; you need to be a first-rate Sherlock Holmes. Like Holmes, smart patients ask intelligent questions and have the instincts (and guts) to politely challenge things they don’t understand. They don’t need to know the most esoteric medical details, but they need to put at least as much effort into finding out the basics about their health as they did in getting the driving directions to our office. Ultimately, you are the person most responsible for the success of your health. Here, what great doctors know that great patients can learn.

1. Get your stories straight. Bring your spouse or partner to your doctor’s appointment when you’re giving your health history or describing a problem; there are a lot of questions that only a partner can answer (such as how many times an hour you stop breathing while asleep). But beware the doc’s sixth sense. When you tell us that you rarely tear into the Pringles after 8 p.m. or that you’ve been taking your cholesterol-lowering drugs with the discipline of a Marine, your spouse will shoot you (or us) a look that says, “Are you kidding me?” We never miss it. And hey, sometimes your spouse wants to blow your cover. It’s called love. But if you try to snow us, we might try to trip you up. For example, we’ll ask if you’re fit enough to climb three flights of stairs. You’ll say yes, unless you’re over 85 or bedbound. Then we’ll ask, “When was the last time you climbed three flights?” You’ll say “Maybe a month… ” and your spouse will send a look that says, “You haven’t climbed three flights of stairs since we voted for Ike.”

2. Truth or consequences. We know you bend the truth a little when telling us the good and bad you do to yourself. That’s why we at least double, up or down, the most fudged claims. For example:

3. Nurses know it all. One way to find a great doctor is to grill the head ER or ICU nurse at the largest local hospital, preferably a teaching hospital. These nurses get a battlefield view of doctors at their best and worst. If you’re visiting someone in the hospital, you may be able to swing into the unit. If all hell isn’t breaking loose and the nurses have a few relatively quiet minutes, you’ll have a chance to politely approach one and make your inquiry. A nurse may say, “Well, to be honest, Dr. Addison is a complete jerk and everybody hates him, but if you’re in serious trouble, there’s nobody better.” Endorsements like this aren’t unusual in medicine.

4. Get friendly with your pharmacist. Your pharmacist is the least expensive and most accessible health resource you have. While it might seem easier to forge a personal relationship with one pharmacist at a small mom-and-pop pill dispensary, smart patients can and do establish great relationships with superstore pharmacists too. You can see her anytime you want, without an appointment — all consultations free. In medicine, that’s extraordinary. Your pharmacist has an amazing wealth of knowledge at her fingertips, which means at your fingertips. Many also have access to new technology that can answer questions (such as, Is it safe to take this brand-new medication with this even newer medication?) in a blink. What’s more, they get a soldier’s-eye view of patients with similar conditions using different medications every single day. They see who improves, and who complains about side effects. And they know which side effects could mean serious trouble. Why do so few people take advantage of this golden resource? It baffles us.

5. Learn the shorthand. When your doctor hands you a script (that’s doctorspeak for “prescription”), she knows you can’t understand the arcane Latin-y squiggles and abbreviations. Doctors typically write the name of the medicine first, then the form (say, capsule or tablet), dosage, amount (say, 30 tablets), directions for taking it, and finally the number of refills.

6. The waiting game. When you’re anxious for test results, don’t think, No news is good news. It’s no news. Too many patients wait for the doctor to call them with results, or they figure that silence means everything’s fine. Smart patients always ask when the results will likely be in, and they call the office that day. And the next day, and so on. It’s an extra reminder for us to call the lab if it’s running behind. A postcard from the lab may have been lost. And in a bustling office, records can sit for a day or two without us knowing. So be a nudge.

7. Get with the plan! If a doctor doesn’t accept your insurance, but he is really your top choice, don’t give up. Call the insurance company and ask if it would consider adding this doctor to the list. If it won’t, ask why. Sometimes, if even just a few patients ask the insurer to add a doctor, and the physician approves, the company will agree. Likewise, ask your doctor if you could persuade him to begin accepting your insurer. And every year when you renew your health insurance (a lovely period, usually in the fall, called open enrollment), call your doctor’s office and make sure it intends to keep accepting this insurance plan. When we’re deciding which insurance carriers we’ll work with, we can be swayed by just a few small factors — and if dropping a plan will create big problems for two or three regular (and well-liked) patients, that can carry weight. So speak up.

8. Learn from the past. Consider having an autopsy performed on your parents when they pass away. Few are done today compared with decades ago, as it’s rarely thought necessary when a cause of death is clear. Although it can be expensive, there’s much value in knowing if your 82-year-old father has undiagnosed prostate cancer that had been advancing since his 50s, or heart disease even though it was a stroke that did him in. This is especially useful if the death was due to an accident. Reassure your living parent this doesn’t mean that foul play is suspected, there can’t be an open casket, or the body will be shipped to a CSI sound stage.

9. Need surgery? Hunt for the specialist’s specialist. You don’t just want a doctor who is comfortable with performing a particular surgery as part of a wide repertoire; you want the surgeon who is obsessively focused on the exact technique you need done. Today, one surgeon can gain so much experience with one very specific surgery that her patients have fewer complications than the national average. Aside from asking your regular doctor to point you to the maestro of your surgery, doing Internet research can help you locate such a hyper-specialized surgeon. You just have to hope that one works at your hospital (and takes your insurance plan), or a road trip might be in store. And make sure your hospital is Joint Commission accredited for quality and safety. Go to qualitycheck.org to find the best hospital for you.

10. Meet the doc behind the scenes. If you’re having surgery in a hospital, you need to meet the anesthesiologist face-to-face and give him some dirt on you, such as the last time you had general anesthesia, exactly how much you drink, what drugs you use and how often. People who recreate with substances can keep their habit hidden from lots of people, but they’d better be up-front with the anesthesiologist, since narcotics and other drugs can increase the amount of anesthesia needed, and you don’t want to be wide-awake when the surgeon asks for the knife. The anesthesiologist also needs to know how physically fit you are, any allergies you have, and (for the umpteenth time of your hospital stay) every medication, herbal remedy and supplement you take. What about those nightmarish stories you’ve heard about patients waking up during surgery? It’s rare, but it happens. Talk to your anesthesiologist about this, and ask if a medical device that monitors wakefulness is available and should be used.

11. Customize your living will. The two words living will evoked about as much emotion as life insurance did not long ago. But that was before Terri Schiavo captured the country’s attention in 2005. Living wills became a vogue subject, even among people under 40. Yet there’s no one-size-fits-all living will. If things should take a particularly unhappy course and you can’t speak up for yourself, you can tell hospital staffers ahead of time which measures you do or do not want to receive, such as:

Artificial breathing. No, not via the services of one of the more attractive hospital staff members, we’re afraid. Instead, you’re placed on the machine called a ventilator, which pumps air into your lungs.

Artificial feeding. If you’re unable to eat, you can be given nutrients through an IV or a tube that’s inserted into your stomach. Some of our more industrious friends have asked if they could have this procedure done just as a matter of convenience, but we tell them to slow down, take a break and eat a real meal.

Cardiopulmonary resuscitation (CPR). You know, the organized theatrics you’ve seen in TV shows and movies, when a hospital team tries to revive you after your heart stops beating or you stop breathing — unless you request a do-not-resuscitate order (DNR). Unlike on television, however, there is not a 99.9% chance that you will be revived successfully and to full consciousness within five seconds by a tanned actor, but we’ll try our best.

That’s why Blue Cross and Blue Shield of Illinois (BCBSIL) is participating in the Federal Reserve Bank of Chicago’s Money Smart Week April 20-26, an educational effort that teaches people ways to manage money wisely.

“By simply asking questions and being aware of your insurance options, you can have an impact on your financial health and better prepare for retirement and other life changes,” said BCBSIL President Paul Boulis. “No doubt, people are aware of increasing health care costs and know their need for services will increase as they age, but many people don’t plan ahead.”

Recent statistics show that almost half of American workers report total savings and investments (not including their primary residences or any defined benefit plans) of less than $25,000, even though it’s estimated that retirees will need approximately $225,000 to pay for health care alone. Consumers need to learn to more accurately estimate their medical expenses in retirement and to understand how to pay for them to protect their assets.

So how can people plan ahead for health care costs in a way that is both realistic and effective?

People can start by learning about the savings and insurance alternatives available. Options include:

– Health Spending Accounts (HSAs): Many people use HSAs to pay short-term health care expenses rather than as a savings vehicle. But HSAs also fit within the broader scope of funding for care during retirement.

– Long-term Care Insurance: According to a recent Employee Benefits Research Institute study, only 32 percent of workers believe they will not have enough money to cover health expenses and 44 percent believe they will not be able to cover long-term care. Long-term care insurance addresses this concern and helps protect retirement savings.

– Medicare Supplements and Part D: The incremental cost of these products is relatively small compared to the value they provide. For instance, consumers can purchase Medicare Part D plans, some of which cost only $30 per month. These plans cover up to $2,510 in initial drug costs and also provide rich catastrophic benefits.

– Annuities: Annuities may help people meet long-term retirement needs, but many do not understand their potential and the role they play in retirement planning.

The vote on the Genetic Information Nondiscrimination Act – or GINA – was 95-0.

The bill would prohibit health insurers from asking for or using genetic information to make a decision about coverage or to set premiums.

The potentially vast promise of a new era of personalized medicine based on genetic information has long been haunted by a disturbing possibility: The same genetic tests needed to identify potential victims of diabetes, glaucoma and other diseases could also be used to discriminate against them in hiring, promotion, medical insurance and other practical necessities.

As a result, even patients whose family histories put them at risk have been leery of getting tested. But now Congress is moving to eliminate that fear and encourage patients to take advantage of what could be a revolutionary change in medical diagnosis and disease prevention and treatment.

“We are on the threshold of a new era, because for the first time, we act to prevent discrimination before it takes hold,” said Sen. Olympia Snowe (R-Me.), one of the original advocates for the bill in the Senate. “We are taking a stand that as we look to the future, genetic discrimination will not be allowed to flourish, to take root.”

“Since no one is born with perfect genes, each one of us is a potential victim of genetic discrimination,” said Rep. Louise Slaughter (D-N.Y.) sponsor of the first legislation introduced in Congress, in 1995.

It has taken more than a decade for the bill to finally come to the verge of becoming law because the House and Senate had previously failed to coordinate their actions. Moreover, business and insurance groups worked behind the scenes against the legislation, arguing that genetic discrimination is not a major problem, and that many states already had laws against it.

While people with group health insurance are already protected to some degree under existing federal laws, those who are self-employed and buy coverage on the individual market previously had no guarantees that their genetic information would not be used against them.

Under the bill, insurers would also be forbidden to raise premiums for a group because one or more members had genes that would predispose them to an illness. That particular protection is seen as important for small businesses that offer health coverage, because a sudden spike in rates can lead small employer to cancel coverage altogether.

Employers, unions and employment agencies would be prohibited from requesting or using genetic information for hiring, promotions, assignments or firing. A compromise worked out earlier in the week made it clear that employers – particularly large companies that self-fund their healthcare costs – could not be sued twice under the law for the same violation, both as employers and as insurers.

But the bill’s protections do not extend to other forms of insurance coverage, such as life insurance and long-term care coverage. And even after passage of the antidiscrimination legislation, advocates warn that the government must still address major shortcomings in the regulation of labs and the tests themselves, to ensure accurate results.

Until recently, genetic tests were used mainly for rare conditions. But there are currently more than 1,200 diseases for which genetic tests are available in medical laboratories, and that number is expected to grow as scientists devise new tests for common conditions such as diabetes.

“It’s the first civil rights bill of the new century of life sciences,” said Sen. Edward M. Kennedy (D-Mass.). “We made sure today that our laws reflect the [scientific] advances we are making. The promise of new science will be inadequate if our laws fail to contain the right protections that genetic information will not be abused or misused.”

This week, the House passed legislation that included a provision to require every HSA transaction be reviewed and verified as a legitimate medical expense. Democrats say this is to ensure that consumers are using their tax-free withdrawals for a knee replacement, rather than a new iPod. In reality it adds a layer of bureaucracy that could sharply reduce the appeal and cost savings of HSAs.

A key player here is Ways and Means Health Subcommittee Chairman Pete Stark, whose main purpose in politics is to give the U.S. a government-run health-care system. He is a known opponent of HSAs – once comparing them to “weapons of mass destruction” – because they introduce more individual choice into the health-care marketplace.

Pushing for the provision was a company called Evolution Benefits, which has patented a system for the substantiation of health-care expenses. Evolution’s lobbyist, John McManus, was the former staff director of the Health Subcommittee under Republican Bill Thomas. The company first lobbied for the HSA provision, then withdrew its support when Republicans began to focus on its role. But Ways and Means Chairman Charlie Rangel helped make sure the provision was in the bill, which passed largely on partisan lines.

Liberals claim HSAs are insurance for the “healthy and wealthy,” but there’s little evidence this is true. How they work is that an employer or individual first buys a cheap, high-deductible policy for large, unexpected medical costs. Then the insured can open an HSA and make an annual contribution up to $2,900 for an individual in 2008, which he can use to pay for ordinary health needs. Savings not spent in any given year can build up tax-free.

This is health insurance many Americans can afford, and it doesn’t force those who have better use for their scarce dollars to buy gold-plated insurance with special-interest mandates (cover the chiropractors!) that Democrats want to force on everyone. HSAs also give consumers more reason to care about prices, bringing much-needed market discipline.

Since HSAs were created in December 2003, 3.2 million HSA accounts have been opened, covering 4.5 million Americans. Nearly a third of new HSA users previously had no insurance and bought coverage on their own. Thirty-three percent are small businesses that had not previously offered coverage to their employees. Isn’t this what good progressives claim to want?

Apparently not if it means a free market in health insurance. Having lost the policy argument when HSAs were created, Democrats are now trying to kill them with regulatory subterfuge. The new scheme purports to ensure that money saved tax-free in an HSA is actually used for health expenses. But this is a nonproblem: Any withdrawal from an HSA is already subject to a federal tax audit, just as individual tax returns are. In any case if people cheat on their HSAs, they are only cheating themselves. When a medical expense arises below the insurance deductible, they will be the ones paying for it, whether from their HSA or another bank account.

Democrats, including Hillary Clinton and Barack Obama, decry the high and rising costs of health care, including insurance “overhead.” Mr. Stark and his friends want to impose the same bureaucratic overhead even on spending that consumers do with their own money. The Senate should stop this one dead in its tracks.

While the Democratic candidates want to use government as a lever to aid the 47 million U.S. citizens without health insurance, Sen. John McCain would rely much more heavily on the free market. The likely Republican nominee has begun charging that his Democratic rivals “want government to take over the health-care system.”

With Sens. Hillary Clinton and Barack Obama focused on their own contest, Elizabeth Edwards, wife of former candidate John Edwards, has stepped in and begun attacking the McCain plan.

Though Mrs. Edwards says Democrats aren’t proposing government-run health care, she finds it ironic that Sen. McCain is so averse to it given that he has had nothing but such coverage since birth. A young John McCain was first insured as the son of a Navy man, then as a Navy officer himself and finally as a member of Congress.

“He has not spent a single day not protected by a federal health plan, not a single day of his entire life, and yet he denigrates this care,” said Mrs. Edwards, who recently joined the Democratic-leaning Center for American Progress as a senior fellow.

While Sen. McCain agrees with the Democrats on some issues, such as climate change and, after some initial resistance, aid for struggling homeowners, differences on taxes and other economic issues, including health care, are likely to be a sharp contrast.

The Democrats’ priority is to cover all, or nearly all, the uninsured, except for several million illegal immigrants. Both candidates would have government set up a marketplace where people could buy coverage from private companies or the government, with subsidies for lower-income earners. The candidates also would bar insurance companies from rejecting people with pre-existing conditions or charging them more.

While Sen. Clinton would mandate that everyone be insured, Sen. Obama wouldn’t — a difference that has been a source of debate between them.

Sen. Clinton has charged that Sen. Obama’s plan would leave millions of citizens uninsured; Sen. Obama has countered that people will get insurance once it is affordable. Many health economists agree with the New York senator, but Sen. Obama’s position might be easier to defend in a general-election debate.

While Sen. McCain regularly attacks both Democrats together, he has made clear he is particularly prepared to attack Sen. Clinton on the issue of mandates, which, he says, bolsters his argument that Democrats are heavy-handed and would leave citizens with less choice.

The Arizona senator dismisses the fact that people could choose which health plan to sign up for under either Democrat’s plan. “If you mandate, as Sen. Clinton wants to do, then, yeah, you’ve got a choice, but you still have a mandate. That’s like saying, ‘You’re going to be executed — do you want a knife or a bullet?’ ” Sen. McCain told reporters aboard his bus.

Sen. Clinton’s policy chief, Neera Tanden, replied: “That’s a great choice of words when literally people are dying.”

McCain aides concede that their case against Sen. Obama could be weaker, given that the Illinois senator’s plan doesn’t have mandates.

Sen. McCain doesn’t think it is up to government to ensure that all citizens are insured. He simply wants to give people more control and, like Sen. Obama, says people will buy insurance if it is affordable.

The centerpiece of his plan is severing the link between health insurance and employment. Under existing law, citizens get a tax break on the cost of their health insurance only if it comes through an employer. That partly explains why 170 million citizens get insurance through an employer.

Sen. McCain would replace the existing tax break with a refundable tax credit ($2,500 for an individual; $5,000 a family) that would go to all citizens with insurance, no matter how they got it. The result would likely be an erosion of employer-sponsored insurance and an increase in plans bought on the open market.

“The biggest fear people have when they lose their job is losing their health insurance,” Sen. McCain said last week in an economic speech. “I have proposed comprehensive reforms that will lead to innovative, portable insurance.”

Democrats say his plan would be great for young, healthy people who could get a good deal on their own. But he hasn’t solved the difficulty faced by older people and people with pre-existing conditions buying insurance on the open market.

Mrs. Edwards notes that the McCain plan could leave both him and her out were they forced to seek insurance on the open market. Both have had cancer, and insurance companies typically won’t offer insurance to people applying on their own who have had serious medical problems.

Sen. McCain said last fall that he would help people with particularly expensive health-care needs by offering special subsidies administered through Medicaid, the state-run health program for the poor. But how that would work or who would qualify is unclear.

Sen. McCain also would let people buy health insurance across state lines. That would allow health-insurance companies to escape state regulations they don’t like, such as rules allowing for appeals when companies deny coverage and rules requiring insurers to cover people with various conditions or to cover particular types of treatments. The companies would likely gravitate to the states with the regulations they most favored.

The result is that health-insurance companies would all operate out of states with few regulations, effectively stripping state rules built over decades, Mrs. Edwards said. “We can expect all our health-care policies to be written in states where little is required of them.”