Risk-adjusted rates or a case of gender discrimination?

That's exactly what Connecticut lawmakers are trying to figure out, according to the Hartford Courant. This week, lawmakers heard testimony on a proposal to ban the consideration of gender in determining health insurance rates on the individual market.

A report released by the National Women's Law Center in September found that 40-year-old women in Connecticut pay an average of four to 48 percent more for health insurance than 40-year-old males enrolled in the exact same plan. The range of variation in premiums increases for women over 55—they can pay anywhere between 37 percent more or 22 percent less than their male counterparts.

President Obama, with Florida Republican Gov. Charlie Crist at his side in a bipartisan example that maybe some folks in Washington might want to pay attention to, held a town meeting in Fort Myers on Tuesday and told the crowd how and why health reform was part of his economic recovery agenda. He made the connections between the cost to families and the cost to the whole strained economic system, and pointed out the waste and frustration that could be reduced if we moved from massive paperwork to streamlined computerized health records. Here's the exchange:

QUESTION: Welcome to southwest Florida. In light of the fact that you've inherited an economic crisis, where does your priority lie with health care reform?

OBAMA: Well, it's a great question.

And I think it is — there are some people who are making the argument that, well, you can't do anything about health care because the economy comes first. They don't understand that health care is the biggest component of our economy and, when it's broken, that affects everything.

Michael Courtney was 41 years old when he was diagnosed with a rare form of lymphoma. It started on his tongue, but spread quickly. He has had radiation and chemotherapy. Treatment will continue indefinitely. So will his bills.

An auto mechanic, Courtney was hesitant about changing jobs because he didn't want to lose his health insurance. But a new employer promised immediate benefits so he took the job. He was even able to stay with the same insurance company that he had at his old job. But a month into the new job, he found that the new policy wouldn't cover his cancer for three months. His disease was a pre-existing condition. Already strapped with medical bills, he postponed treatment.

Courtney's story is one of 20 real-life experiences of patients that gives the human dimension to a new report by the American Cancer Society and the Kaiser Family Foundation released Thursday. Based on calls to the Cancer Society's insurance help line, the study called "Spending to Survive" concluded that after a cancer diagnosis, the financial implications may not be the first concern "but for many, it soon becomes one." Even people with health insurance face enormous financial obstacles to care.

Our readers know that we give Massachusetts a lot of credit for forging ahead with its program to cover everyone, although we recognize the economic and logistical challenges. The Boston Globe takes a closer look at how families are cobbling together coverage, even in Massachusetts, where unemployment has reached a 15 year high. Here are three stories that the Globe's Kay Lazar found when she looked "at the people behind the statistics."

Vivian Izuchi, 53, a married mother of three, lost her job as director of a church after-school program. She got another similar job fairly quickly, a blessing in this economy. But the last one had health coverage. This one doesn't. "I am investigating everything and anything I can," she told the newspaper, as she sorts through a "maze of state-subsidized programs" to see if her family qualifies. Her husband is now unemployed, so no on-the-job insurance option there.

"The whole world is in recession. But the United States is the only wealthy country in which the economic catastrophe will also be a health care catastrophe—in which millions of people will lose their health insurance along with their jobs, and therefore lose access to essential care."

That's how Paul Krugman began his latest column, reminding us what's at stake. Today's economic indicators are grim, and the headlines are full of more job cuts.

Krugman asks, "Why has the Obama administration been silent, at least so far, about one of President Obama's key promises during last year's campaign—the promise of guaranteed health care for all Americans?" We aren't quite as impatient. The inauguration was only 10 days ago, HHS Secretary-designate Tom Daschle hasn't been confirmed, we know there's a ton of preparatory work being done on the Hill, and we've been hearing for a while that health reform wouldn't really start moving until March anyway.

But it's still worth listening to Krugman's reminder of why we can't be lulled into thinking health reform can wait:

Let me address three arguments that I suspect Mr. Obama is hearing against moving on health care, and explain why they're wrong.

Although the name might lead you to think of retail clinics, Lola Butcher's new article from HealthLeaders Magazine titled "Medicine at the Mall" actually talks about taking over THE WHOLE mall.  Yes, really.

But it's not as crazy as it seems.  The article highlights the experience of Vanderbilt University Medical Center, who after watching the costs and headaches rise from expanding its downtown campus, looked at the cost of taking over an aging, half-vacant shopping center.  They could get quite a bang for their buck, it turned out.

It's worse than we thought. No not just the economy, although we say that pretty much every time we look at the headlines. We're talking about the cost of COBRA.

We've posted recently on the high cost of COBRA, and the relatively few people who lose their jobs who can afford to extend their job-linked health insurance this way (here and here). Congress is likely to include significant COBRA subsidies as well as more short-term Medicaid and SCHIP options in the stimulus package to help more people stay covered in the economic crisis. A recent Commonwealth Fund study suggests the problem is more severe than we thought; earlier studies put the COBRA take-up rate at about 12 to 15 percent, but Commonwealth finds that 2007 data suggests that only about one in 9 or 10 percent of unemployed workers have COBRA coverage. (Some are able to get on a spouse's health plan, or find alternative health coverage). Here's the summary:

We are a bit late getting to Atul Gawande's New Yorker article on health reform, and we wondered whether to post, or whether many of you had read it. But then we remembered a lesson from a complicated pregnancy: even during three months of strict bedrest, it's impossible to keep up with the New Yorker. So for those of you who still have the magazine with this excellent piece on your bedside table, here goes:

The essay, "Getting There From Here," starts with the obvious: people who don't have health insurance have sad stories to tell, and sad stories can compel a society to change. At least it compelled every other major industrialized democracy (and some non-industrialized, non-democracies, but Gawande doesn't dwell on those) to make sure people get health care. But maybe we are at the point finally when we, as a society, with a new leader, will find those stories not just sad but unconscionable.

You may have seen reports last week (New York Times, Wall Street Journal, among others) that China is planning to dedicate $123 billion by 2011 to covering its 1.3 billion people. Analysts saw it as both a move to protect and improve health care in both rural and urban China as well as a stimulus to domestic spending in a country with a high savings rate. One reason the Chinese save: concern about high out-of-pocket health costs.

The state news agency Xinhua reported. "Growing public criticism of soaring medical fees, a lack of access to affordable medical services, poor doctor-patient relationship and low medical insurance coverage compelled the government to launch the new round of reforms." Sound familiar? Alas, in China the health insurance subsidies cost around $17 per person. The goal is to cover 90 percent of the population by 2011, and get that last 10 percent by 2020. (We've read several articles about the plan but aren't sure who the uncovered 10 percent are.)

Not a subtle headline in Sunday's Washington Post Business section. But then it's not a subtle problem. The article, "A Premium Sucker Punch: Soaring Insurance Costs are a Blow, Even When Employers Cover More of the Tab" told us that, guess what, what we are saving on cheaper gas is not coming anywhere near what we are spending on higher health insurance costs.

Premiums are rising. So are out-of-pocket costs and deductibles. Overall, health costs are rising faster than wages.

A growing number of workers in 2009 will pay more for health benefits—and in some cases receive less coverage—as their employers grapple with the financial fallout of rising medical expenses and diminished revenue and profits, recent surveys of human resource officials show.

The Corporate Executive Board found in its survey that a quarter of officials from 350 large corporations said they had increased deductibles an average of 9 percent in 2008. But 30 percent of the employers said they expected to raise deductibles an average of 14 percent in 2009. Mercer, a global benefits consulting firm, surveyed nearly 2,000 large corporations in a representative poll and found that 44 percent planned to increase employee-paid portion of premiums in 2009, compared with 40 percent in 2008.