As governors gear up to deliver their state-of-the-state addresses later this month, the Democratic and Republican leaders of the spoke Wednesday about the broader policy challenges facing all states in 2013 — and sure enough, health care was among the major issues both mentioned.

The “State of the States” addresses by Delaware Gov. Jack Markell, a Democrat, who is chair of the NGA, and Oklahoma Gov. Mary Fallin, a Republican, who is vice-chair, was a first for the group.

Fallin, who and expanding Medicaid in Oklahoma, said that all states hope to see some flexibility from the federal government as they implement the health care law.

“We would … like to see the administration embrace innovation at the state level by speeding up the consideration of waivers” for Medicaid, the joint state-federal program for low-income people, she said.

As an example, Fallin pointed to her state’s plan, which through a Medicaid waiver, gives employers premium subsidies to help buy insurance for low-income workers. That waiver program expires at the end of the year.

“Unfortunately we received word not too long ago that Insure Oklahoma and its waiver itself could be in jeopardy,” putting the program’s future in question, she said.

Markell told the audience that Delaware had opted to set up a health insurance exchange, or marketplace for small businesses and individuals, in partnership with the federal government.  But, he added, other states may not follow suit because they have different health care needs.

He said Delaware policymakers did not see the expansion of Medicaid as a political issue. “For us, this was not a Democratic issue, this was not a Republican issue— this was an issue of math,” said Markell. “It just worked out, and it turns out that we believe it’s a good investment for us to make sure that more people were covered through this expansion, while at the same time federal reimbursement for Medicaid actually increases for some of the people we were already serving.”

In addition to the remarks about health care policy, the NGA also announced a new in seven states: Alabama, Arkansas, Colorado, Kentucky, New Mexico, Oregon and Virginia. The initiative will be led by Gov. Robert Bentley of Alabama and Gov. John Hickenlooper of Colorado.

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But a in the suggests that consumers’ perceptions of prices could lead them to the wrong conclusions. At a low price, something like a flu shot signals “great communal benefit – an item that is accessible because people need it to be healthy,” the authors said.  “Conversely, high prices signal reduced accessibility and hence less need.”

That kind of thinking can lead to bad, possibly dangerous, health decisions if consumers decide there’s less risk in foregoing higher-priced health products and services.

“Price and risk should be very independent from one another, when you think about consumers making informed health care choices,” said , a professor in Tulane University’s A.B. Freeman School of Business and a co-author of the study.  “But now we see that they are very dependent on one another, in the same way that price and quality are very dependent on one another, and that can lead to some inconsistencies in health care purchases.”

To understand how and why consumers react to prices, the authors presented two flu shot prices to two groups of people. One group was told the price was $25 and other was told $125. Even though everyone was told their insurance would pay for the vaccine and that it would be good for individual or public health, price was crucial. Participants were “more likely to believe that low price reflects high communal need for the vaccine,” while high prices translated as less accessibility and therefore less need.

The study raises a cautionary flag for policymakers: Making price information available isn’t sufficient. “Increased consumer education” about need and risk are also required, the authors said.

For now, medical price transparency is more . It’s hard, if not impossible, to comparison shop, because hospitals and doctors typically don’t post prices in the way retailers do and often charge varying amounts for the same services. Jeanne Pinder is among those consumers trying to do something about this. The former New York Times reporter runs a new website called . It presents the highest and lowest sticker prices of various medical procedures, from blood tests to mammograms, and leaves the rest up to the consumer.

“I’m not going to tell you what to do with this information,” Pinder said. “But I am empowering you with this information.” The site offers the Medicare price as well as what’s been reported at various hospitals and medical practices. So far her site looks at 20 different medical procedures offered by providers in New York City and San Francisco.

Pinder said “as we head down the road towards this thing called ‘consumer-driven health care’ we want to know what that really means and in order to do that, as consumers, we need to know how much it costs.”

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The law has provisions that transition from a traditional fee-for-service system, where doctors, hospitals and other providers are paid based on how many patients they served and the specific treatments or episodes of care for those patients, to new payments models that change incentives in a variety of areas. This new payment reform includes rewards for high quality care, bundled payments to cover a spectrum of providers and treatments for a patient, giving providers a set fee for managing patients care and also giving them a share of any savings.

The report estimates savings from payment reform to be anywhere from $200 billion to $600 billion over 10 years. But the report, released Wednesday at the , finds misgivings among providers.

A survey of doctors by Harris Interactive finds that 59 percent of physicians believe that the fee-for-service system encourages them to provide “an appropriate level of care.” Only 15 percent disagreed. Although 37 percent of doctors thought such a system encourages the use of more care or expensive care, 38 percent also said that a fee-for-service system encourages coordination of care. Not surprisingly, the 400 U.S.-based primary care physicians and 600 U.S.-based specialists surveyed, did not favor the idea of a global capitation payment—or a fixed payment per month for all medical services. Nearly 60 percent of the doctors surveyed said that capitation put too much risk on the provider.

Furthermore, “physicians’ views did not differ substantially based on the size of their practice, even though doctors in larger practices would be less exposed to insurance risk under capitation.” Doctors also estimated that their practices get up to 68 percent of their revenue from fee-for-service payments.

Harold D. Miller, the executive director of the , says that policymakers can’t expect physicians to take accountability for things they can’t control or influence. “Alternative payment systems need to have appropriate risk adjustments, risk limits, and risk exclusions,” he says. “Most of the broad-based payment reforms in the Affordable Care Act, including , are just small [pay-for-performance] incentives added on  top of the existing fee-for-service system. You don’t fix the barriers and disincentives of fee-for-service by adding a new layer of [pay-for-performance] on top of it; you have to completely replace fee-for-service.”

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Look at just one of yesterday’s marquee games: The contest between the Baltimore Ravens and the Pittsburgh Steelers in Ravens’ tight end Dennis Pitta and the Steelers’ running back Isaac Redman receiving concussions. A Steelers’ defensive lineman, Ziggy Hood, also left the game with a back injury.

Given the increased interest in providing better care for players, including more , National Football League officials announced Monday a new way to track and treat injuries.

The NFL said it is implementing an electronic health records system that will eventually be adopted by all 32 teams. The system, which will be phased in over two seasons, will take the place of paper medical records and will be completely transportable, from hand-held devices to hospitals, tracking a player’s injury and medical history, and even providing medical personnel video footage of player injuries. That will make is easier for doctors to have access to a player’s complete record, especially if they are injured while playing on the road.

Players will also be able to provide their records to their personal physicians.

Next season eight teams (the New England Patriots, New York Jets and Giants, Baltimore Ravens, Pittsburgh Steelers, Houston Texans, San Francisco 49ers and Denver Broncos) will keep their player’s health information electronically. By 2014 the entire league will transition to electronic health records. The NFL estimates that its 10-year contract with , based in Westborough, Mass., will cost anywhere between $7 million to $10 million.

“We’ve always embraced technology,”  Brian McCarthy, the NFL’s vice president of communications said. “We see this as a great opportunity for medical personnel: providing them even more tools to do their work in real time.”

Records will be able to move with a player, should they be traded to another team, and are touch and speech-capable. Girish Kumar Navani, the CEO and co-founder of eClinicalWorks, says the implementation of EMRs creates a much more fluid system of care coordination.

“We are making the scope of this medical data digital. Which means the pharmacy will be connected electronically, as well as the labs and the diagnostic medical imaging centers.” All this, Navani says, will be shareable with the team as well as other medical staff.

Incorporating video streaming is a new feature for eClinicWorks, and Navani says that it will allow doctors will be able to see what exactly caused a player’s injury. Currently the NFL has an injury reporting system in which data is entered manually, but Navani says that the new EMRs will sync with the current technology of the league, including a web-based application about concussion injuries.

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´¡Ìý released this week from the University of Michigan reveals that roughly 115,000 American women lose their private health insurance annually after a divorce and about half of them do not get replacement coverage. The researchers also said this is not a “temporary disruption.” They found that “women’s overall rates of health insurance coverage remain depressed for more than two years after divorce, as long as our data allow us to test.”

“We really build on past research that shows that many women experience large declines in income and assets after divorce,” said , a Ph.D. candidate at the University of Michigan and co-author of the study. “And we wanted to look at health insurance coverage for women after divorce because we see it as another extremely important economic resource.”

Lavelle and her co-author , the director of the University of Michigan’s Population Studies Center, analyzed data from the U.S. Census Bureau’s , which focuses on household income. Lavelle and Smock looked at data that spanned four years and observed women who were married, stayed married, or divorced at some point during that time.

They found that approximately six months after divorce, 15 to 20 percent of women lose their coverage.

Interestingly enough, Lavelle says data shows that the lack of coverage for these women can be partially attributed to outside factors like dips in income. “But the event of divorce itself appears to explain a good part of the decrease in health insurance coverage in these women’s lives,” she said.

The study notes, “Not all women are equally likely to lose health insurance after divorce. Those insured as dependents on husbands’ employer-based insurance plans are most vulnerable to insurance loss, while stable, full-time employment buffers against it.” They found that women from moderate income families, those making between twice and three times the federal poverty level, or about $46,000 and $70,000 for a family of four, are at high risk of losing insurance in a divorce. “Many of these women fall into the ranks of the near-poor after divorce, with too much money to qualify for Medicaid but not enough to purchase private health insurance coverage,” the authors write.

There are other options for divorced women, however: Federal law allows ex-spouses to extend their coverage through the federal Consolidated Omnibus Budget Reconciliation Act law, also known as , for up to three years. But premiums for this kind of coverage are expensive because the individual picks up the entire cost of the policy.

Some states employ programs that allow an ex-spouse to simply pay the premium of the employer-based insurance, rather than the costly COBRA plan. But their provisions can vary and Lavelle notes that some states do not include self-insured plans offered by many large businesses.

, the director of Health Research and Education at the says this study is timely as the health care law will implement new insurance options for consumers.

Fronstin says women coming out of a divorce with a smaller income may be eligible for subsidies for health care when that provisions of the law takes effect in 2014. Furthermore, a wider group of consumers will be eligible for Medicaid, which may help some women left uninsured after a divorce.

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The updated figures come from , a non-profit group that works to improve the health of mothers and babies, which released its annual Tuesday. It gives the U.S. a ‘C’ in overall preterm birth rate reductions. And according to the and the American College of Obstetricians and Gynecologists, one out of eight babies is born prematurely in the U.S. each year.

In a , the March of Dimes noted that the U.S. ranks 131 out of 184 countries — putting it close to countries such as Somalia, Thailand and Turkey.

According to their data, the U.S. preterm birth rate is now at the lowest rate in a decade. Dr. Jennifer L. Howse, the president of the March of Dimes and a member of the , said that for 30 years up to 2006 the U.S. preterm birth rate had been increasing. (KHN is an editorially independent project of the Kaiser Family Foundation, which also supports the commission.)

“That’s a profoundly disturbing trend in birth outcomes,” Howse said. But for the last five years, the rates have been steadily decreasing in almost all states.

The March of Dimes’ goal is to bring the national preterm birth rate down to 9.6 percent by 2020. Four states earned “A-Ratings” on their report card: Vermont at 8.8 percent, Oregon at 9.1 percent, New Hampshire at 9.5 percent and Maine at 9.6 percent. The worst states on the report card included Louisiana at 15.6 percent and Mississippi at 16.9 percent and the Commonwealth of Puerto Rico at 17.6 percent.

Howse pointed to a that notes that premature births cost the U.S. $26 billion a year. But she said this year’s improved numbers could have “potential savings of roughly $3 billion in health care and economic costs to society.” According to their data, approximately 64,000 fewer babies were born preterm in 2010 as compared to the peak year in 2006.

From this year’s report card, Howse said her group noted four evidence-based interventions that can contribute to lower premature birth rates: insuring soon-to-be moms, reducing the number of scheduled deliveries, investing in smoking cessation programs and investing in progesterone therapy that helps to delay early contractions.

The report card also notes that the rate of uninsured women of childbearing age increased to more than 21 percent since last year. Experts say uninsured women who are pregnant may forgo vital prenatal care during their pregnancy. According to the report card, seven states including the District of Columbia reduced their number of uninsured women.

Howse said that states that fared better on the report card ensured better access to health care. “It means that women of child bearing age have access to their physicians — that risks are detected earlier rather than later. I do believe we will start to see that kind of halo effect in our maternal and child health outcomes once the [Affordable Care Act] is fully implemented,” she said.

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That’s what a Stanford University professor asked in a nationwide in collaboration with the Robert Wood Johnson Foundation, GfK and the Associated Press.

The survey, which was conducted in 2010 and in 2012, showed more than 2,000 participants 18 different statements about the health care law. Twelve of those statements correctly portrayed provisions of the law and six of them were false. Participants were also asked to how certain they were of each of their answers.

, a social psychologist and a professor of communication and political science at Stanford University and a co-author of the report on the survey, said no one identified all 18 statements correctly on either the 2010 or the 2012 survey. Still, in 2012, the survey found fairly high numbers of correct responses. For instance, 80 percent of respondents knew that the law allowed adult children to stay on parents’ health plans and that companies with more than 50 employees are required to provide coverage to workers.

But the researchers pointed out that those results were not authoritative since participants may have been guessing. That is why they included the question about the participants’ certainty in their answers. “When taking into account people’s certainty ratings, we observed much lower levels of accurate knowledge…,” they write. “Indeed, only one provision was correctly identified with high certainty as being part of the ACA by a majority of respondents. Fifty-two percent … correctly said with high certainty that children under the age of 26 could get health insurance by being included on their parents’ health insurance policies. All other provisions of the law were correctly identified with high certainty by less than 40 percent of Americans.”

The report also shows that participants’ responses fell within their party lines. Democrats were more knowledgeable about the health care law than Independents, who, in turn, were more knowledgeable than Republicans. Also, older respondents were able to answer the survey more accurately.

But Krosnick said that one of the most striking findings from the survey was that respondents liked the provisions of the health care law regardless of political allegiance.

“When you say: should families be allowed to keep children on their health insurance to age 26? —Most people like most of these provisions. So there’s every reason to have imagined that the public would support [the law]. So our point is that lacking full knowledge [about the health care law] leads to much less enthusiasm about it.”

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It’s no secret that reforming the country’s health care system is an important issue in this year’s presidential election. According to a recent survey from the New England Journal of Medicine, one out of every five voters sees the 2010 health law as a top priority, but many are also still perplexed by it. That confusion has led about 15,000 physicians and medical students from around the country, working through the grassroots advocacy group , to take on the challenge of explaining the measure to patients and providers.

The group, which first took shape in 2009, launched a bus tour in late August as part of its “Patients Over Politics” campaign. The tour visited points between the Republican National Convention in Tampa, Fla., and the Democratic National Convention in Charlotte, N.C. Along the way, its members spoke with more than 5,000 people.

Dr. Vivek Murthy, an attending physician at and the co-founder of Doctors for America, views this kind of physician involvement as critical to addressing the ills of nation’s health care system.

A number of national medical professional organizations, such as the and the , endorsed the health law and are now working to shape the implementation of specific provisions. Murthy says, though, that Doctors for America is unique in that it attempts to link its members on the ground with patients, community leaders and lawmakers to advance understanding of the overhaul and continue to build on it.

“We thought this is a moment where maybe we can make sure things are different – where we can bring physicians together to have more of an active voice,” Murthy said.

KHN’s Shefali S. Kulkarni spoke with Murthy, who also serves on the White House’s and whose organization has become a non-profit project of the . Edited excerpts follow.

Q: What motivated the bus tour?

A: The whole reason we began our campaign was to take this message to politicians in both parties and to communities. Our thesis going in was that people didn’t care if it was a Republican or a Democrat pushing for health care; ultimately what they cared about was how it could make their lives better.

People would tell us they were worried about how expensive insurance had become [or] that coverage wouldn’t be there for them when they got sick. We also heard a great sense of confusion — people had heard all kinds of myths and rumors that scared them [or] they just didn’t know what the [law’s] benefits were. There was a 23-year-old man at the University of South Florida who told us he was uninsured and fell sick last year. He told us, “Now I have a huge insurance bill and I’m in debt and I’m trying to finish school and after all that I still don’t have insurance.'” He didn’t know about the provision that could allow him to stay on his parents plan till he was 26. His eyes really lit up when we told him this.

Q: What’s the next step?  

A: We’re organizing in states like Ohio, Massachusetts, Florida, and hopefully more states to get doctors [and] patients to sign “declarations of delivery”… to declare their support for the Affordable Care Act. We are going to deliver those declarations to elected leaders in those areas.

Q: And what about after the election?

A: The outcome of the election doesn’t change our mission. It isn’t about the party. It’s about building a sustainable system where everyone has access to quality health care. And that will require advocacy and hard work regardless of who wins the White House.

If President Barack Obama is reelected our goal is to make sure the health care law is implemented so that it will maximize benefits for patients. And we will go into communities and continue to explain how patients can take advantage of these benefits. We will also be pushing the president to go beyond the health law to make sure that we have a health care system that works. If [former Massachusetts] Gov. Mitt Romney is elected we will have to see what he intends to do with the law. He’s been running on a platform of repealing it, but there are already a lot of components of the health care law in place. We would work with the Romney administration to see that it is kept in place and perhaps build on it.

Q: How did Doctors for America start?

A: For years my colleagues and I noticed that people come into the medical profession with high ideals—wanting to help patients and do good for their community. But once they get into the practice of medicine they realize the system is broken. Many physicians have found themselves spending more time with paperwork than with patients, and feel like their soul is kind of being sucked dry. That is what’s driving so much of the burnout and the stress. It wasn’t just the fact that the health care system was broken — it’s that they were losing a sense of hope that it could actually get better — and that was the part that was most alarming to me. So we wanted to use the voices of doctors to move the health care system in a direction that ultimately places physicians and patients at the center of the discussion.

Q: If Doctors for America is a means to get physicians’ voices talking about changing the health system, what do doctors really want to happen?

A: If you talk to people on Capitol Hill, and you ask them, “What do doctors care about?” they’ll tell you two things: doctors care about medical malpractice and they care about reimbursement. What is frustrating to many doctors is that that didn’t really reflect the values of doctors who care about the quality of care we are delivering. So during the run up to health care reform we surveyed physicians on what their priorities were.

Physicians often told us that they thought it was a travesty that we had such a high uninsured rate — a rate that was only getting worse. A second big priority is that they wanted to improve and strengthen primary care. A lot of primary care docs and specialists see the system as increasingly untenable –both the quality of the work and in the reimbursement. That was leading to more burnout among primary care docs and it wasn’t an attractive option for medical school students. A third priority was ensuring we had a large enough workforce — enough physicians and nurses — to provide patients with adequate access to care.

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The 44-year-old recalls sneaking a box of colorful ice cream cones from the kitchen and eating as many as she could alone in her room.

Over the years, she found herself repeating that practice in sporadic, emotional episodes that left her with an overwhelming sense of shame and guilt.

“I realized that food was the one thing I could have for myself and I could sort of escape … and it made me feel good,” said Turner, who lives in Annapolis, Md. “Over time it became a way for me to disassociate from my problems or whatever I was trying to avoid.”

Turner was suffering from —a mental health condition that includes significant overeating brought on by depression and other emotional issues, according to mental health experts.

She has been treated for the condition for more than 20 years. Even though she has health insurance, obtaining coverage for the wide array of treatments has been problematic. Her plans would cover some treatments for depression, but not many other services, such as nutritional counseling with dietitians. At one point, she paid up to $200 a week to meet with a dietitian. This back and forth between coverage and her expensive out-of-pocket costs led to gaps in her treatment.

“It took me a long time to get to anything that even looked like recovery,” Turner said.

According to the , a lobbying and advocacy group based in Washington, D.C., 14 million people are affected with , and binge eating disorder. And for many of these patients, getting a full range of insurance coverage can be difficult. Mental health coverage is often less generous than coverage for physical ills. In addition, helping eating disorder patients is complicated because it involves medical care, mental health services and nutritional therapy, requiring a team of specialists – often a primary care doctor, a therapist, a psychiatrist and a dietician. Patients argue that insurers don’t adequately cover all those services.

The coalition tried unsuccessfully to get eating disorders included in the “essential health benefits” the health overhaul law requires insurers to provide beginning in 2014. “Exclusion of eating disorders is all too common on the part of insurers seeking to limit interventions deemed non-essential,” the group wrote to federal officials in a in a January . “Despite being biologically based mental illnesses with potentially severe physical health ramifications, including death, eating disorders are all too often found on lists of benefit exclusions.”

The group noted that a survey of more than 100 eating disorder specialists found that “96.7% believe their patients with anorexia nervosa are put in life threatening situations” because treatments often are cut short when coverage is denied.

But insurers say that experts have not identified clear protocols for treatment. They note that there is little research on how best to treat the mental and the physical aspects of an eating disorder.

“Any eating disorder is a complex condition,” said Diane Robertson, director of the ECRI Institute, a nonprofit organization in Plymouth Meeting, Pa., that conducts research for insurance companies, hospitals and other health care groups.

“[Eating disorders researchers] haven’t done a good job in doing outcomes research and finding what combination of treatments work.”

Susan Pisano, a spokeswoman for America’s Health Insurance Plans, the industry trade association based in Washington, D.C., says that insurance companies are not hesitant to cover the behavioral and physical treatments for other chronic conditions such as diabetes.

“For diabetes you have the physical aspects that are treated and then you have behavioral issues addressed as well,” she said, citing exercise and courses on better nutrition as examples. “But for eating disorders, there’s a lack of evidence for what works and what doesn’t work.”

To be sure, such disputes are not limited to eating disorders. With rising health care bills, insurers have demanded more rigorous evidence of the effectiveness of many treatments and pushed patients to cover a greater share of their medical costs across the board. Patients, in turn, have mounted consumer campaigns to pressure insurers and even turned to lawmakers and regulators to force insurers to cover a variety of diagnosis. For instance, strong parent advocacy efforts led , despite insurers’ concerns about the cost.

Mark Chavez, an associate director at the National Institute of Mental Health’s Research Training and Career Development Program, said there is no silver bullet when it comes to the treatment of eating disorders.

“I don’t think it is accurate to talk about treatment for eating disorders as if there is a single eating disorders (there isn’t), or a single treatment for the different eating disorders,” he wrote in an e-mail.

Treatment Decisions

On its , the institute says “specific treatments” for chronic cases of the diseases “have not yet been identified.” Treatment, “often tailored to individual needs,” can include antidepressants, group counseling sessions, individual therapy, consultations with dietitians to help reeducate patients on hunger, nutrition and satiety, the institute says. In extreme circumstances, patients are hospitalized; some may have to be fed through a tube.

Those hospitalizations can include care for electrolyte depletion, irregular heartbeats and over hydration caused when patients consume too much liquid to try to hide their weight loss. Some patients are also referred to a residential facility for mental health care.

Insurance companies often limit the amount of hospital coverage, because it is costly and they say the length of stay is unpredictable.

Angela Woods runs the department that deals with insurance authorizations for in Chicago, Ill., which treats patients with eating disorders and other mental health issues. Insurance companies “are more willing to authorize treatment for mood disorders [such as depression and anxiety] than they do for most eating disorders,” she said. “And they also will generally authorize for a longer period of time for the mood disorder.”

One of Insights’ patients is Melissa Rothman, a 37-year-old fourth-grade teacher from Evanston, Ill. She sees a dietitian and attends group therapy sessions to treat her binge eating disorder. She said her cravings for high caloric, salty “trigger” foods are slowly subsiding. Her insurance, however, covers only half of the cost of her treatment and limits her to seven visits to Insights before the plan requests a progress review. She ends up paying about $75 out of pocket per visit, so she reduced the amount of times she sees her therapist.

“I’d hit a Thursday session where I was supposed to go in, but I didn’t know if I was covered by my insurance,” she said.

Ilyse Simon, a registered dietitian in Kingston, N.Y., who mainly works with eating disorder patients, said insurance coverage for her services is spotty. Part of the problem, she said, is there’s a stigma associated with the condition.

“Anything that revolves around eating or lack of eating — there is a sense of personal responsibility,” said Turner, who has been in recovery from bingeing for the last seven years. “People think: ‘Just tell her to eat,’ or ‘Tell her to stop eating,’ or ‘go on a diet,’ they don’t realize that this is a serious mental health issue.”

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Yesterday Palmer tweeted about her struggles with insurance coverage after reading a by Nicholas Kristof. Kristof wrote about his college roommate who is now uninsured and struggling with Stage 4 prostate cancer, and the issue hit close to home for the rock star. When she was 21, her older stepbrother died from Lou Gehrig’s disease. Because he lacked health insurance, his medical bills put a big strain on the family’s budget.

“It was really difficult for my whole family. He got really sick, really fast and everyone scrambled around trying to make ends meet,” Palmer said in a phone interview on Monday. “It was only a few years later that I graduated from college and found myself in the position of being uninsured.” She wrote a describing how after a long fight with her parents, she agreed to pay half the cost for her insurance, while her parents paid the rest.

“I remember really, really reluctantly writing my mother those checks for $115 when my rent was $350, so my insurance was almost half my … rent. I would have so much rather spent that money on concerts, buying music and books,” Palmer said. “But I had really seen the cautionary tale up close and I knew it was smart to be insured.”

On Twitter, Palmer wanted to know if there were others out there who struggled with insurance coverage. So on Sunday night she asked her more than 690,000 to reply with:

• What country they are from
• What is their profession
• If they are insured, or if they aren’t, why they are not, and how much their insurance costs per month

She labeled the tweet with the hashtag and within a few hours she had a massive response. “I think I probably got more than 2,000 responses to the question,” she writes on her blog. A few notable tweets came from Dr. Atul Gawande, a contributor to the New Yorker and a surgeon at Brigham and Women’s Hospital in Boston, Wil Wheaton, an actor from Star Trek: The Next Generation and Palmer’s husband, British author Neil Gaiman.

.@ @ My answer: 1) US 2) doctor/writer 3)Yes 4)Yes: >$1000/mo for family of 5.

— Atul Gawande (@Atul_Gawande)

@ Actor. Insured through my union, eligibility determined by earnings. I worry I won’t make it every single year.

— Wil Wheaton (@wilw)

@: 1) USA 2) writer 3) Yes 4) Writers Guild of America. Free but I have to write a certain amount of films/TV a year to qualify.

— Neil Gaiman (@neilhimself)

But what surprised Palmer the most was the reactions Americans had to those who tweeted from outside the U.S. and vice versa.

“What was really interesting about what has happened in the past 24 hours is that people from overseas are shocked by the stories from Americans. And the teens and perhaps less educated people here in America are shocked that this [lack of insurance coverage] isn’t happening overseas,” said Palmer. So far she’s received tweets from the United Kingdom, Australia, Germany and a handful of other countries.

With the surge of tweets — already the hashtag has ‘trended’ on Twitter — Palmer asked for help tabulating the data on the incoming tweets. A woman from Michigan took on the task of collecting all the data Twitter users were providing. So far, 24.5% of the U.S. respondents do not have health insurance because of costs. 31.4% were from outside of the U.S. and all but one had some form of required health insurance. Palmer said she is looking forward to getting more data as the tweets slow down.

But why poll Twitter to learn about the uninsured and insured around the world? Palmer said she was just curious, but surprised to see that she could get people to open up about their coverage and bring insight in the health care debate — something she says politicians have been struggling to do. “I feel like I’m in such a cool position,” she said. “There are these two giant things that are disconnected, and I just bridged the gap and stand by and watch everyone talk to one another. I was thinking this just this morning politicians, health care reformers and people who are really full time invested in this issue, they spend their lives trying to figure out how to get this exact conversation going.”

In the meantime, Palmer is preparing to go on tour tomorrow. She’ll be traveling to 11 cities throughout Europe, but she said she’ll keep an eye on Twitter to see where the conversation goes. She’s been constantly tweeting her reactions and retweeting responses, all the while keeping her stepbrother in mind.

“People can relate.  He was classically uninsured, in the same way I’m seeing people on my Twitter feed,” said Palmer. “He was a painter, a writer and a musician and so I worshiped the ground he walked on. His death really hit me hard. And in all of these people I see a little glimmer of him.”

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