All posts by pennygentieu

Dear Bob Latta

Dear Representative Latta,

Thank you for your letter dated April 28 in reply to my letter dated March 7 in regard to healthcare reform. You state that “we need to empower states to deliver health care solutions that lower costs, increase quality, and improve coverage.” Here is why that will never work in Ohio:

The special interests of the health insurance industry are even more cozy with the state of Ohio than it seems they are with Congress, if that could even be possible. It is the lobbyists who control everything in Ohio, from educational luncheons with our legislators, to the wording of laws that are written to control them, to the actual running of the insurance department. It’s so crowded in Columbus with special interests, that there is no room left for the interests of the people who live in Ohio.

I have written to you about these issues several times in the past year, in fact I made an entire website based on these issues, OhioCitizenRateReview.Info.

In case you never read my website, this is what the state of Ohio has done with their empowerment that they’ve had in the past seven years:

1. Ohio lets every rate hike go through no matter what. Every rate hike the insurers want, the insurers get, regardless of how unrealistic it is for the economy of Ohioans.

2. Ohio does this in secret, without “Effective Rate Review”, a “check and balance” that was provided for in the ACA law. With several million dollar grants from the CMS, Ohio was supposed to have set up a transparent system for citizens to be informed and have open discussions about the annual rate hikes the insurers ask for every year. But they don’t. They keep everything as secret as they possibly can.

3. In secret, and without properly addressing my 2015 complaint, Ohio allowed Medical Mutual to eliminate their PPO insurance in the individual market, after granting Medical Mutual rate hikes of 373% over seven years. About 100,000 Ohioans were personally affected by this elimination of Medical Mutual’s PPO, which was the only national network insurance available in Ohio to individuals. This was probably the biggest market share, but Ohio let them do it, without any fanfare, without any discussion, and at the same time, while rewarding Medical Mutual with the state of Ohio’s employee insurance business. Ohio employees get Medical Mutual PPOs, but not the individuals of Ohio.

4. Complaints made to the Ohio department of insurance get buried. So that Ohioans who have problems with insurance companies in the state of Ohio have absolutely no voice and their problems have no resolution.

5. Our provider networks in Ohio are unacceptably inaccurate. This falls under the jurisdiction of Ohio laws as well as federal laws. A new state law was passed last year that was supposed to ensure their accuracy, but Ohio won’t enforce it. Last summer I called all the PCP doctors in the ACA networks in Toledo listed as accepting new patients, 308 doctors, and only 20% were actually accepting new patients. 10% in the “affordable” plans. I informed you, you did nothing. I informed my state representatives, they did nothing. The New York Times reported on it in December. Not a peep from you, but your colleague in Lima, Jim Jordan, spoke out in favor of the flawed directories, saying “It should surprise no one that the Ohio Department of Insurance’s physician directories are so flawed, considering how flawed the Affordable Care Act (ACA) is.”

And now you want to give the state even more control so that they can further pervert our healthcare system for their own personal greedy purpose.

You were elected, Bob Latta, to represent us in Congress. It’s your responsibility to look out for us on a federal level. We didn’t elect you for you to skirt your responsibility and send it back to the states.

We need healthcare to be thought of as a public good, and not a Wall Street money machine. We have a democracy, not a monarchy. Money is not king. You were elected by the people, not appointed by lobbyists who crown you with their favors.

As I wrote in my previous letter, you should be addressing the problems of healthcare costs instead of letting them grow and grow.

It’s absolutely a lie for you to say in your letter that the AHCA will lower premiums by 10% and allow us to keep our doctors. Premiums for those over 50 will go up five times as much as it will cost others, and millions of people will not be able to keep their doctor because they will not be able to afford insurance anymore.

If you can’t give us what we need, or at least enforce the laws that can fix the problems with the ACA, then just leave it alone, so that we can vote you out of office, and elect a Congress who will give us what we need.

Sincerely,

Penny Gentieu

Noblesse Oblige

My Northwest Ohio federal and state senators and representatives, governor, with the lieutenant governor who is also the director of the insurance department, and the state Medicaid director.

We elected these people but King Moola rules.

Please can they throw us some crumbs.

Click on the crowns to read about my representatives. I’m deeply disappointed that they won’t fix the problems that are completely in their control to fix right now, like the highly inaccurate provider networks, and the transparency that the ACA provided for that they won’t abide by, and that they won’t pass an emergency “any willing provider” law so I can take my insurance dollars to my own doctor, and I’m shocked that when they say they are going to give us something better than the ACA, that they only think of the insurance industry, still putting profits over people. King Moola rules. Please, mini Moolas, please please throw us some crumbs!

If you are going to let yourself be crowned by the lobbyists, at least understand the concept of noblesse oblige. It’s like this: the masters must be responsible for those they tame.

Medicare for All NOW!

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Click on this image to see the Kaiser Foundation’s Interactive Map of Tax Credits under the Affordable Care Act vs. the American Health Care Act, sure to make you very sick when you see what our House of Representatives has been up to in the past two months.

My call to Rep. Latta and follow-up letter on March 7.  Please call too — 202-225-6405

Dear Representative Latta,

How is it right that this country further discriminates against certain groups of Americans when it comes to healthcare?

Why aren’t you addressing the real problem which is the amount of money we spend on healthcare and the rate in which it’s going up each year, at an unsustainable rate which has grown to be 18% of the GNP and is actually estimated to be 30% in 2040?

Why are pharmaceutical companies allowed to price-fix generic drugs to jack up prices by 8,000%?  Why are they granted orphan status which permits extremely high prices on mainstream popular drugs like Abilify, Crestor, and Humira, the best-selling medicine in the world?

What about all the hospital mergers, and the secret prices with no transparency, and the double-digit premium price hikes? What about the skinny provider networks with 80% inaccuracies? What about families plagued with medical bankruptcies?

Since everybody needs healthcare at one time or another, why don’t you treat it like a utility that we all need that is publicly regulated, or like the fire department that is paid-for through taxes?

Instead, the House of Representatives does nothing to address any of these problems. You come out with this extremely regressive, insulting, age-discriminating bandaid to the current Affordable Care Act and call it the American Health Care Act.

Under this law, is it fair that people in their fifties and sixties will be paying five times more than others?  Do you think we really have the money to pay that, when health insurance has already gone up for us 350% in the past ten years?

When the median family income in Lucas County is $41,777, how can you think it’s okay for health insurance to cost $25,000?  Or do you think that healthcare is something only for the rich? Of course the average family can’t afford it. So what do you do but take the subsidies that were income based, and you make them age based, across the board, to everyone regardless of their wealth, to continue this medical industry corporate welfare.

Don’t you think that the underlying costs that make health insurance so expensive should be put in check? Have you considered that the high administration costs, adding up to be at least 30% of our total healthcare costs, could be kept down to 5% if we didn’t have hundreds of insurance companies trying to manage our healthcare, instead of just one manager, such as Medicare?

Do you really think that in 2017, Americans do not deserve healthcare? All Americans deserve affordable healthcare, and it will be affordable when people are put first, before special interests. We demand Medicare for ALL.

Sincerely,

Penny Gentieu

“Yes Ms. Gentieu, you really do live in Russia.”

pg24-25After nearly nine months since I made a query with the Ohio Inspector General to look into certain issues at the Ohio Department of Insurance, I received an email response on March 8, posted below. Coming one day after the unveiling of the utterly regressive Republican answer to our healthcare problems, it’s like they are trying to tell me something.  

“Yes Ms. Gentieu, you really do live in Russia.”

But we live in America and we were promised a better, less expensive healthcare plan that wouldn’t leave people dying in the streets.

(Related: Letter to Rep. Latta)

JUNE 29, 2016
Dear Ohio Inspector General:
  1. The Ohio Department of Insurance is granting double-digit rate hikes without any public review, without lowering the hikes. They are basically working for the insurance companies at the expense of millions of Ohioans, including me, whose insurance went up 373% in 7 years, same company.
  2.  The Ohio Department of Insurance is not releasing public documents to me about consumer complaints.
  3. The Ohio Department of Insurance is not releasing rate review justifications for the public to participate in “effective rate review” — with the 5 million dollars in CMS grants meant for this purpose. Other states save their people millions — even a billion — using public rate review, but not Ohio.
  4. The Ohio Department of Insurance has no problem with health insurance companies advertising phony provider networks. There’s no fine or punishment for lying to the public or to the enrollees, so health insurance companies are allowed to rip us off blind!

None of this seems right; or good in the least for the citizens of Ohio, me included. Please investigate.

Ever since I’ve lived in Ohio, my Medical Mutual health insurance rates have gone up double-digits every year. I’ve had the same, or essentially the same health insurance plan with Medical Mutual. I’m a small business person, so I buy individual insurance. The year the plan went on the Marketplace, in 2014, my Medical Mutual premiums went up 224%! The price of my 2016 Medical Mutual insurance is now 373% more than my Medical Mutual insurance was in 2009! In just seven years it went up 373%! The benefits, including the provider networks, of the Medical Mutual insurance in 2009 through 2016 are basically the same.

All of these rate increases were approved by the Ohio Department of Insurance. I found out recently that the state of Ohio received huge multi-million dollar grants from the HHR to assist in the transparency of health insurance rate reviews, and to assist in the containment of rate hikes. The most recent grant was given to Ohio just this month. What does Ohio do with these grants? Other states have saved their citizens at least a billion dollars in rate hikes by using these funds for “effective rate review.” But not in Ohio. The state of Ohio grants rate hikes just as much as the insurance companies ask them for. Double-digit rate hikes, no problem! And Ohio keeps the process secret from their citizens, who they do not engage in “effective rate review.”

I’m not only robbed of my rights, I’m made to be a stooge to the Ohio health insurance industry, an industry that seems to have the Ohio Department of Insurance wrapped around its finger.

I’m just one person getting robbed, in the company of millions of other people getting robbed too – people facing double-digit health insurance rate increases year after year, whether or not health insurance is a part of their employment or they buy it individually. Unsustainable rate increases are happening to everyone in Ohio. Because in Ohio, whatever the insurance companies want, the insurance companies get.

Have you seen lately how we rank as a state? Ohio is the most expensive state for health insurance, see this April 2016 Department of Health and Human Services Brief, Table 4, page 9.

Not surprisingly, not only is the insurance way too expensive, the quality is questionable. A big problem exists with phony provider networks. I made two complaints to the ODI about this issue (see, CareSource complaint here). I wanted to see what other complaints have been made. I requested public records of health insurance complaints, but my efforts were completely thwarted by the Records Custodian at the Ohio Department of Insurance. After six weeks of hassle with them, they gave me a list of 50 complaint numbers and ODI employees the complaints were assigned to, with no other information — not even the the names of the insurance companies that were complained about!

No doubt a problem exists with phony provider networks, because Ohio has no regulation allowing for a punishment or fine for health insurance companies that have phony provider networks. That wouldn’t be something the insurance companies would want, so the Ohio Department of Insurance doesn’t impose such regulation.

Recently, the Ohio Department of Insurance secretly approved the merger of Aetna and Humana, burying the document deep in their website. It didn’t matter to the ODI that the Ohio legislative Insurance committees requested an investigation and public hearing. It didn’t matter to the ODI that consumer groups requested an investigation and public hearing. The ODI went right ahead and gave the insurance companies exactly what
they wanted, without any consideration to what the public and the elected officials asked for — an investigation and public hearing. A simple investigation and public hearing to consider the pros and cons of a merger between two companies representing such a
huge percentage of the market, and how that would affect Ohioans. Hmmmm……

There’s no other way to put it — it’s like we live in Russia.

It is appalling – the lack of transparency in this state!   And that’s not all.

Is it too much to ask from Ohio for the state insurance department to look after the best interests of its citizens when it comes to healthcare, instead of entirely, quite blatantly, enabling the health insurance industry to take utter advantage of us, and strip away any value to what they are selling, as well?

It’s killing us.

I hope you will consider the issues that I have brought up, and help in these ways:

The Ohio Department of Insurance should release public records upon request. Consumer complaints should be searchable on their website, similar to how they are on the Ohio Attorney General’s website, or better yet, like they are on the Texas Department of Insurance’s website. The ODI should do something constructive with the complaints that consumers make, and not just treat them like hot potatoes that they can’t throw far enough fast enough, that they completely erase after only TWO YEARS!

The ODI should create an effective rate review program like many other states have, such as Vermont. The ODI should not grant every rate hike the insurance companies ask for, rather, they should make the process public, and have public hearings about rate increases, in an effort to keep the annual rate hikes down.

It seems obvious, but the Ohio Department of Insurance needs to start serving the needs of Ohioans.

And finally, the ODI should tell me why they allowed Medical Mutual to raise my rate 224% the year it went on the Marketplace and 373% since 2009. (consumer complaint no. CSD-0034217.)

Their response, nearly nine months later:

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The Price I Have to Pay

PG245180-Edit 2February 17, 2017

Lisa Iannotta
Office of the Ohio Attorney General
Collections Enforcement Section 150 E. Gay St.
Columbus, OH 43215

Dear Ms. Iannotta,

I reluctantly enclose a check for $10.05, the price I have to pay to get to see public records about provider network insurance complaints, only to find out that the Ohio Department of Insurance buries our complaints.

I resent having to pay anything to find out what a poor job the Ohio Department of Insurance is doing in regard to protecting Ohioans. The Ohio Department of Insurance should have to pay me, for all the time and trouble I had to go through, to learn the true fate of the complaints made by the citizens of Ohio, which is straight to the graveyard in the middle of the night.

The Ohio Department of Insurance should do their job, and that means they should clean up the provider network directories that Ohioans are complaining about, and not to make our complaints secret and delete them completely after only two years.

I resent that the Ohio Department of Insurance made this comment to the New York Times reporter, in the enclosed December 4, 2016 article in the New York Times, Insurers’ Flawed Directories Leave Patients Scrambling:

Enforcing [directory-accuracy rules] is “consumer-driven,” said David Hopcraft, a spokesman for the Ohio Insurance Department. The state does not check the lists until consumers report inaccuracies, one doctor at a time.

But the Ohio Department of Insurance doesn’t even do that much. The Ohio Department of Insurance makes provider network complaints confidential, shuffling them to a different office (the department undertaker) where they claim everything must be confidential by law. Then they bury them in secret — our provider network complaints are buried without a funeral or even a wake — we are never told what happened to our complaints, but we know for sure that they never saw the light of day.

Sincerely,

Penny Gentieu

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Penny Gentieu found many health insurance directories to be outdated and inaccurate.
Penny Gentieu found many health insurance directories to be outdated and inaccurate.

The Wild Wild West of American-style Pharmaceuticals

Pierre scans July 20160012

This is my great great grandfather’s photo of the Kickapoo Indian Medicine Company.

The Kickapoo Indian Medicine Company, of New Haven, Connecticut, sold “patent medicine” before they had patents for medicine. They sold snake oil when it was the cure-all. They weren’t really Indian. Kickapoo Medicine was often laced with alcohol, morphine, opium, or cocaine.

Fast forward to 2017. The shenanigans continue. Many mass market brand-name drugs that are nearing the end of their patent and even after the patent is over are being given orphan status. Orphan status allows the drug company to have a longer period of exclusivity on a drug and raise the price even higher than it was before.   Drugmakers Manipulate Orphan Drug Rules To Create Prized Monopolies     see also Orphan Drugs Lookup  new on Feb 10: Grassley launches inquiry into orphan drugs after KNH investigation

Meanwhile, generic drug manufacturers, taking advantage of patents that are no longer exclusive, have colluded with other drug manufacturers who make the same drug to raise their prices as much as 8,000%. A lawsuit is pending.   Alleged Scheme To Fix Generic Drug Prices Started At Dinners And ‘Girls Nights Out’

And now Trump wants to loosen regulations to encourage start-ups and get drugs to the market faster —  TRUMP’S PLAN FOR LOWERING BIG PHARMA DRUG PRICES COMES AT A HIGH COST

YEE-HAW!

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U.S. Congressman Jim Jordan’s ignorance and broken moral compass is not surprising

knowing that he’s a member of the “Freedom Caucus”

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John F. Kennedy would have cared. Pastel by my mother, Audrey Gentieu, 1964.

Congressmen are supposed to be concerned with the wellbeing of the people in the state to which they serve. But U.S. Representative Jim Jordan went out of his way to make uncaring comments on the report of Ohio’s highly inaccurate provider networks by Kaiser Health News and the New York Times, and how Ohio’s inaccuracies are the worst in the country, and that the state insurance department does nothing to fix the problem. (New York Times, December 4, 2016, Insurers’ Flawed Lists Send Patients Scrambling)

80% inaccuracies and people can’t find doctors. But here’s what U.S. Representative Jim Jordan, from Lima, Ohio, has to say. in a January 9, 2017  interview by Patient Daily.comFlawed ACA physicians’ lists are no surprise, Ohio congressman says

“It should surprise no one that the Ohio Department of Insurance’s physician directories are so flawed, considering how flawed the Affordable Care Act (ACA) is.”

“It’s sadly no surprise that the doctors’ lists were flawed as well,” Rep. James “Jim” Jordan (R-OH) said during a Patient Daily email interview. “Health care will be better and more affordable when Obamacare is gone.”

The Ohio Department of Insurance does not have physician directories, the insurance companies do, so Congressman Jim Jordan doesn’t know what he’s talking about. Yet he feels compelled to blame the ACA for it. The ACA has nothing whatsoever to do with the phony provider network directories of the health insurance companies that sell plans through the Marketplace.

U.S. Representative Jim Jordan’s ignorance notwithstanding, honestly, how can a U.S. Representative go on record saying that the 80% inaccuracies are not surprising? Has he no sense of right and wrong? Has he no empathy for his constituents and neighboring citizens of Ohio? 80% is a devastating percentage of a provider network to be found inaccurate. It happens to be the worse percentage of any survey yet reported from any state in the United States. Ohioans are hurting, and Rep. Jim Jordan is not helping!

Provider network directories are regulated by the state of Ohio and have existed long before Obamacare.  Most other states have accurate physician directories that people who are looking to buy insurance can use to properly assess the health insurance networks and find doctors who are accepting new patients like the list says. Many states have strict laws concerning the accuracy of their lists, and if the lists say they are accepting new patients, they are accepting new patients, and not just 20% of the list, as I have proven in Toledo.  Ohio does not have strict provider network directory laws and what little regulation the insurance companies have, is regulated by the Ohio Department of of Insurance, which is just like being regulated by the insurance company itself.

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The New York Times, December 4, 2016. Also published on Kaiser Health News.

Response to Findlay’s Mary Taylor article

The Courier, January 12, 2017   Lt. gov. says Obamacare not working

I’m sorry for Findlay losing their major insurer, Medical Mutual and their PPO. We lost them in Toledo too, in fact, all over the state, they are gone. It is a tragedy that Medical Mutual has been allowed to withdraw their long-standing PPO from the individual market, the only insurance they ever offered Ohioans before 2016, and they have been Ohio’s largest insurer since 1934. This is discrimination against a whole class of people, since Medical Mutual still insures Ohio state workers and corporate employees with their PPO, but they no longer offer individuals “real insurance”.  Why was there no public forum about this? No fanfare, no articles by Ohio health journalists, no consumer complaints (like mine) made public by the Ohio Department of Insurance while they let Medical Mutual insanely raise their rates throughout 2014, 2015, and 2016, just to eliminate their PPOs in 2017.

My Medical Mutual premium went up 224% in 2014 when it went on the Marketplace, and double-digits in 2015 and 2016. It wasn’t the health mandates that caused the rate hikes, that Mary Taylor tries to make a big deal of, because Medical Mutual already covered all of that. When I complained to the Ohio Department of Insurance about the crazy rate hike of 224% in the first year, they answered my complaint by giving me Medical Mutual’s answer —  that the Ohio Department of Insurance approved the rate hike so of course it must be okay. Isn’t it cozy how they’ve got each other’s backs?

I wonder how to take Mary Taylor’s statement in this article that insurance went up 91% on average in four years when mine went up 224% in just one year! If she is saying that premiums going up on average 91% in four years is bad, then how could she have ever approved of Medical Mutual’s rate hike of 224% in just one year? And why wasn’t my complaint properly addressed by her? If it had been, then maybe the individual insurance market wouldn’t be compromised today by Medical Mutual’s discrimination against us by the withdrawal of PPOs sold to self-employed Ohioans. She did all she could to usher in this crime against the individual, all in the name of some diabolical political agenda to deny healthcare to the American people.

In 2016, Ohio had the highest premiums after tax credits.  Mary Taylor has assured the failure of the ACA in Ohio in a number of ways. The CMS gave millions of dollars to States to enable “effective rate review.” Our money was used for something else because we never had effective rate review. Effective rate review would have allowed for public forums and open discussions about health insurance prices and problems. Instead, Mary Taylor rubber-stamped any and all rate hikes while keeping the facts far far away from the public. In Ohio, they like us dumb and ignorant.

Mary Taylor allows insurers to maintain provider networks that are on average 80% inaccurate, especially in Toledo where I surveyed them all. What is health insurance if not the provider network? How can insurance regulators allow such extreme dishonesty from our insurers? Why aren’t they looking out for us?

So now with the elimination of Medical Mutual’s PPO, and the total acceptance by Ohio that these new narrow provider networks, that are 80% lies, are just fine, Mary Taylor has the individual market neatly pushed aside as we get slowly snuffed out. We are artists, writers, musicians, inventors, shop owners, entrepreneurs, professionals, and hard-working breadwinners working multiple jobs. And now all of a sudden, we have to choose between having access to great healthcare, like our neighbors who work for the state and corporations, or maybe no healthcare at all, health being something we have to compromise in order to pursue our American Dream?

And what now, does Ohio dream for us? Back to the old, that’s what they want, but at really high prices that the last few years has brought us. Everyone with pre-existing conditions gets thrown under the bus. That would be 25% of us, and the majority would be the older ones my age. Gee thanks, I can’t wait to make it to Medicare age, as the joy of my perky young 60’s instantly taken away.

In Mary Taylor’s glee for dysfunction, the Ohio Department of Insurance laid the perfect backdrop for insurance and hospital hikes and mergers. On their watch, generic drug manufacturers colluded on the price of generic drugs raising prices as much as 8,000%.

And all Mary Taylor can say is, the old laws are in place to fall back on. Regression, regression, regression.

Patient Daily interview

I was interviewed by Patient Daily in regard to the Dec. 4 New York Times article, Insurers’ Flawed Lists Leave Patients Scrambling, specifically about the nitty gritty we face in Ohio with inaccurate provider network directories, the causes and the solutions.

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Patient Daily, December 30, 2016 — Critic claims Ohio doesn’t verify health care provider directory, by Karen Kidd
 "The quote in the New York Times article was shocking," Penny Gentieu, whose odyssey to find health insurance in 2017 involved contacting 308 physicians in six insurance plans, said in an email to Patient Daily. "That the Ohio Department of Insurance (ODI) said that enforcing the directory accuracy rules is consumer-driven by the public complaints of inaccuracies, one at time."
"Things are so bad in Ohio that the legislature last year allowed the Ohio Department of Insurance to write their own rules about how they handle provider network complaints," Gentieu said. "So-called health-watch people in the know objected, but the ODI wrote in a rule that allowed themselves to make entirely confidential any investigation they had about inaccurate provider networks. Which means that not even the people who complained, let alone the public, ever get to know anything about anything they do or don't do to the insurers in regard to their inaccurate provider network directories. Not only do they not do anything, they completely delete the complaints after two years. It's so crazy!"
"The Ohio legislature is controlled by the very rich and powerful insurance and pharmaceutical lobby industry," she said. "They have meetings, lunches and seminars with the legislators that constituents are not invited to and, consequently, the public's issues are never brought to light because we are way-overshadowed by the big money of health insurance and pharmaceuticals. What the legislators know about health insurance is strictly one-sided."
 If state legislators really wanted to do something about this problem, they would make laws with stiff penalties, Gentieu said.
"They would make complaints searchable on the ODI website. They would set up a truly 'effective rate review' annually, with public forums so we have a voice about this extremely terrible problem with health insurance that we face."
"Ohioans have to look under every rock, they have to anticipate any problem, because even though their premiums may have gone up 373 percent -- like mine went up in seven years -- they may only be getting 20 percent of the purported value of the plan."
"Congress should eliminate provider networks, make prices transparent, and take the control out of the hands of the health insurance and pharmaceutical company lobbyists."
"All the doctors should take all the insurance plans. Doctors are either accepting new patients or not. Doctors should not be allowed to lend their names to these plans as if just to beef up the provider network lists to give the insurance plans an illusion of adequacy, when in fact their name listed as accepting new patients when they are not accepting new patients is a total lie. It's false advertising."
"We are small business owners, entrepreneurs, shop owners, artists, writers, musicians and hard-working breadwinners working multiple jobs, " she said. “All of a sudden we have to balance our personal drive and ambitions to our ability to access the best in health care that those working for the government and large corporations are entitled to. It sort of takes down the American Dream, not only for us, but for young people considering their options and people who have a dream but are trapped in their jobs because they provide health insurance."