U.S. Plans to Unveil New Insurance Options

WASHINGTON — The Obama administration plans on Monday to announce scores of new health insurance options to be offered to consumers around the country by the Blue Cross and Blue Shield Association and the United States Office of Personnel Management, the agency that arranges health benefits for federal employees, according to administration officials.

The options are part of a multistate insurance program that Congress authorized in 2010 to increase options for consumers shopping in the online insurance markets scheduled to open on Tuesday.

Congress conceived multistate plans as an alternative to a pure government-run insurance program — the "public option" championed by liberal Democrats and opposed by Republicans in 2009-10.

"The multistate program will help deliver choice and high-value health plans in the new marketplace, expanding quality, affordable options for uninsured Americans," an administration official said.

The administration plans to unveil the program on Monday, the official said, even as Congress fights over the future of President Obama's health care law, intended to provide coverage to more than 25 million people within three years.

Federal officials said they had signed a contract with the Blue Cross and Blue Shield Association to offer health insurance next year in the marketplaces, or exchanges, of 30 states and the District of Columbia. In later years, the officials said, they hoped to see at least two multistate plans in every state, as Congress envisioned.

Under its federal contract, Blue Cross and Blue Shield will offer different products in different states — a total of more than 150 products, including health maintenance organizations and preferred provider organizations, which give discounts for using selected health care providers. In many of the products, consumers will have access to a nationwide network of doctors and hospitals.

The federal government negotiated the benefits and premiums for the Blue Cross and Blue Shield products, so this plan carries a federal seal of approval.

In negotiating with insurers, the Office of Personnel Management leveraged more than 50 years of experience in the Federal Employees Health Benefits Program, the nation's largest employer-sponsored health insurance program, covering more than eight million federal employees, retirees and dependents. Blue Cross and Blue Shield plans are, by far, the most popular among federal employees, with more than 60 percent of the enrollment.

Under the 2010 health care law, the federal government was supposed to sign contracts with at least two multistate plans. But the application from Blue Cross and Blue Shield was the only one approved. Five other companies expressed interest and may file applications in the future, federal officials said. By 2017, at least two multistate plans are supposed to be available in each state.

When Congress was debating the health care legislation in 2009, many Democrats wanted the federal government to offer an insurance plan like Medicare, to compete directly with private insurers in the exchanges. In a letter to Congress in June 2009, Mr. Obama said: "I strongly believe that Americans should have the choice of a public health insurance option operating alongside private plans. This will give them a better range of choices, make the health care market more competitive and keep insurance companies honest."

Republicans resisted the idea, as did the American Medical Association and many drug companies, which feared that a government-run insurance program could set prices and drive private insurers from the market.

Supporters of the multistate plans authorized by Congress say the plans will increase competition in local health insurance markets, many of which are dominated by one or two carriers. The multistate plan will, for example, be available next year in New Hampshire and West Virginia, which would otherwise have just one carrier in their exchanges.

Federal officials said the multistate plan would also be in operation next year in Alaska, Arkansas, California, Colorado, Delaware, Georgia, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Missouri, Montana, Nevada, New Mexico, New York, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Washington and Wisconsin.

Local Blue Cross and Blue Shield plans have been selling insurance for decades, but federal officials said the national plan would offer consumers different products and additional choices.

The multistate plan was also supposed to offer insurance to small businesses, but federal officials said it would provide such coverage next year only in Alaska, Maryland, Virginia and the District of Columbia.

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Op-Ed Contributor: Psychotherapy’s Image Problem

PROVIDENCE, R.I. — PSYCHOTHERAPY is in decline. In the United States, from 1998 to 2007, the number of patients in outpatient mental health facilities receiving psychotherapy alone fell by 34 percent, while the number receiving medication alone increased by 23 percent.

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This is not necessarily for a lack of interest. A recent analysis of 33 studies found that patients expressed a three-times-greater preference for psychotherapy over medications.

As well they should: for patients with the most common conditions, like depression and anxiety, empirically supported psychotherapies — that is, those shown to be safe and effective in randomized controlled trials — are indeed the best treatments of first choice. Medications, because of their potential side effects, should in most cases be considered only if therapy either doesn't work well or if the patient isn't willing to try counseling.

So what explains the gap between what people might prefer and benefit from, and what they get?

The answer is that psychotherapy has an image problem. Primary care physicians, insurers, policy makers, the public and even many therapists are largely unaware of the high level of research support that psychotherapy has. The situation is exacerbated by an assumption of greater scientific rigor in the biologically based practices of the pharmaceutical industries — industries that, not incidentally, also have the money to aggressively market and lobby for those practices.

For the sake of patients and the health care system itself, psychotherapy needs to overhaul its image, more aggressively embracing, formalizing and promoting its empirically supported methods.

My colleague Ivan W. Miller and I recently surveyed the empirical literature on psychotherapy in a series of papers we edited for the November edition of the journal Clinical Psychology Review. It is clear that a variety of therapies have strong evidentiary support, including cognitive-behavioral, mindfulness, interpersonal, family and even brief psychodynamic therapies (e.g., 20 sessions).

In the short term, these therapies are about as effective as medications in reducing symptoms of clinical depression or anxiety disorders. They can also produce better long-term results for patients and their family members, in that they often improve functioning in social and work contexts and prevent relapse better than medications.

Given the chronic nature of many psychiatric conditions, the more lasting benefits of psychotherapy could help reduce our health care costs and climbing disability rates, which haven't been significantly affected by the large increases in psychotropic medication prescribing in recent decades.

Psychotherapy faces an uphill battle in making this case to the public. There is no Big Therapy to counteract Big Pharma, with its billions of dollars spent on lobbying, advertising and research and development efforts. Most psychotherapies come from humble beginnings, born from an initial insight in the consulting office or a research finding that is quietly tested and refined in larger studies.

The fact that medications have a clearer, better marketed evidence base leads to more reliable insurance coverage than psychotherapy has. It also means more prescriptions and fewer referrals to psychotherapy.

But psychotherapy's problems come as much from within as from without. Many therapists are contributing to the problem by failing to recognize and use evidence-based psychotherapies (and by sometimes proffering patently outlandish ideas). There has been a disappointing reluctance among psychotherapists to make the hard choices about which therapies are effective and which — like some old-fashioned Freudian therapies — should be abandoned.

There is a lot of organizational catching up to do. Groups like the American Psychiatric Association, which typically promote medications as treatments of first choice, have been publishing practice guidelines for more than two decades, providing recommendations for which treatments to use under what circumstances. The American Psychological Association, which promotes psychotherapeutic approaches, only recently formed a committee to begin developing treatment guidelines.

Professional psychotherapy organizations also must devote more of their membership dues and resources to lobbying efforts as well as to marketing campaigns targeting consumers, primary care providers and insurers.

If psychotherapeutic services and expenditures are not based on the best available research, the profession will be further squeezed out by a health care system that increasingly — and rightly — favors evidence-based medicine. Many of psychotherapy's practices already meet such standards. For the good of its patients, the profession must fight for the parity it deserves.

Brandon A. Gaudiano is a clinical psychologist and assistant professor of psychiatry and human behavior at the Alpert Medical School at Brown University.

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In Florida, the Front Lines of a High-Pitched, Bite-Size War

MARATHON, Fla. — Much has changed since 1929 when newcomers to Florida, fed up with swarms of mosquitoes, erected a bat tower in Sugarloaf Key, hoping the bats would succeed where they had failed. Badly outnumbered, the bats abandoned the tower, leaving the monumental task to the locals.

It is hard to blame them for trying. In a state largely covered by swamps and marshland, mosquitoes have long killed, sickened, bedeviled, annoyed and outwitted countless residents and visitors. They are no less potent an adversary today as mosquito fighters contend with warmer temperatures, international shipping and travel, and evolving environmental regulations, which have made it simpler for mosquitoes to hatch and travel but trickier to eliminate them.

In July, an outbreak of dengue fever, once thought to have been eradicated in Florida, occurred in Martin County, just north of Palm Beach on the east coast. Twenty people developed the disease, which causes flulike symptoms and extreme aches.

Mosquito control officials are worried that dengue has established a foothold in Florida. The last outbreak — and the first in the state in about 70 years — was in 2009 and 2010, when dengue fever hit Key West.

The problem appears to be contained for now, in large part because the area is small and Florida is well seasoned in the art of mosquito warfare.

"Florida is certainly among the leaders in the world in professional mosquito control," said Walter Tabachnick, a professor at the University of Florida's medical entomology laboratory. "Prior to that, this was not a very nice place to live in."

Imbued with Darwinian strength, the Aedes aegypti, commonly known as the Dengue mosquito because it carries the disease, is a survivalist that breeds and lives in towns and cities. It can encamp inside a bottle cap, under a house or in any container holding water, making it difficult to find and kill.

Fighting them is akin to urban warfare: armed with spray in hand-held devices, mosquito fighters go yard to yard and house to house. They warn residents to remove any containers that can fill with water or tip them over after a rainfall.

"They are sneaky devils," said Gene Lemire, director of mosquito control in Martin County, referring to the insect enemy. "They hide in people's houses, in the dark crevices and in premises where the spray doesn't get to them."

County health officials also are visiting homes to draw blood from people, with their consent, to test for dengue.

Few approach the job of fighting with the innovation of the Florida Keys, which host 45 species.

With a $9.7 million budget, money that comes from a special tax, the Mosquito Control District here relies on two planes, four helicopters and nearly 100 employees to spot mosquitoes and their hard-to-see larvae, track their movements and kill them. Most common are salt marsh mosquitoes and the Aedes aegypti.

The district is considering buying a small drone that can use infrared technology to see hidden pools of water amid tangles of mangroves and sea grass on hard-to-access islands. The drones, about 2 feet long, have never been used for mosquito control.

But a dengue outbreak is unsettling in a state where tourists expect a high degree of comfort. In Key West, where mosquito experts said local officials were slow to react initially, the 2009 appearance of dengue, which is widespread in Puerto Rico, caused some would-be visitors to stay away.

Ultimately, mosquito control employees swung into action, knocking on doors and using both adulticide (to kill adult mosquitoes) and larvicide (for larvae). Mosquito fighters still go door to door in the lower Keys.

Long gone are the days when huge amounts of the insecticide DDT were dropped over wide areas. The use of DDT was banned, with few exceptions, in 1972.

Fighting mosquitoes is particularly challenging in the Keys, and elsewhere in Florida, where large swaths of land are protected by federal and state environmental regulations. Stricter laws mean officials must formulate ecologically friendly pesticides that will not harm endangered species, while keeping pace with bugs that become resistant to certain formulas.

"The noose is tightening on our ability to control adult mosquitoes," said Michael Doyle, the Florida Keys Mosquito Control District's executive director.

So the Keys have shifted mostly to killing larvae whenever possible. Most recently, officials have used a pesticide mist that unleashes minuscule droplets that can more easily float into small containers to kill the larvae of the dengue-causing mosquitoes. New technology allows pilots, who swoop and rise in the air with stomach-churning precision, to more precisely calibrate drops of pesticide according to wind speed and drift.

Some say the best hope in fighting dengue lies in a trial that, if approved by the Food and Drug Administration, could unleash genetically modified sterile male mosquitoes whose offspring would die soon after hatching.

Trials in other countries, including Brazil, have shown sharp reductions in the Aedes aegypti population, according to Oxitec, a British insect control company that is engineering the mosquito. But vocal opposition in the Keys may block the trial, if approved.

Boots on the ground, though, remain essential. Inspectors routinely crisscross mucky mangroves on tiny, isolated islands. In high boots and long sleeves, they scoop up water and look for larvae.

"I absolutely love the swamp," said Yvonne Wielhouwer, an inspector. And then she proves it as she gleefully sloshes across Little Pine Island, keeping a lookout for mosquitoes.

Sometimes they must battle a different species: the scolding Keys resident who readily complains if just a few mosquitoes buzz close to home.

"Someone will be sitting on their porch, and a pilot flies by and kills five billion mosquitoes in the marsh next to them, and they didn't know the mosquitoes were there," Mr. Doyle said. "The next night, they see five mosquitoes on the porch and call in to say, 'What are you going to do about it?' Expectations are much higher today."

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Well: A Youthful Glow, Radiating From Within

At a party I recently attended, a woman in her 60s proudly announced that her periodic facial treatments "have made me look 10 years younger." A man of similar vintage said he was considering "facial tucks" to raise his sagging jowls.

Some days it seems everyone I meet is afraid of getting old — or at least of looking as old as they are. Occasionally, I see women who have had so many face lifts that they can barely move their lips when they talk, let alone smile.

Business is booming in the anti-aging market. Plastic surgeons who specialize in lifts, tucks and fillers barely noticed the recent recession. Cosmetics with anti-aging properties fly off the shelf, and new concoctions appear almost weekly.

I admit to supporting the multibillion-dollar skin care industry with my long use of night creams, as well as a slew of daytime facial and body lotions that purport to "smooth out" aging skin while protecting it with sunscreen. I also color my hair, which in its natural state is now about 80 percent gray.

But I draw the line at injectable fillers and muscle relaxants, face lifts and tummy tucks. I'll do everything I can to stay out of an operating room. My anti-aging measures, if and when they are needed, will be limited to cataract removal, a hearing aid and glasses for driving.

I wear clothes that suit my personality and activities, not necessarily my age. Shorts and tank tops anchor my summer wardrobe. And I wear colors near my face that are right for my skin tone, avoiding those (like yellow) that are unflattering. Still, cosmetic fixes go only so far to counter the effects of time.

True youthfulness — or, I should say, appearing younger than your age — is much more than skin-deep. Research has shown that youthfulness must come from within.

In one study, a team at Case Western Reserve University in Cleveland analyzed the facial photographs of 186 pairs of identical twins, determining which sibling looked older and why. Factors that contributed to looking older included smoking, sun exposure, stress, and depression (or the use of antidepressants), the researchers reported. Other studies have linked depression to higher levels of inflammatory markers and oxidative stress, which can accelerate aging.

The team also found that among those under age 40, a woman with a heavier body looked older than her leaner twin, but in subjects older than 40, a higher body mass index was associated with a more youthful appearance. Fat fills out wrinkles and makes the face — and presumably other parts of the body — look younger. But there's a limit to its benefits: obesity is associated with more rapid biological aging.

Another study published last year by researchers at Brigham and Women's Hospital in Boston found a biological link between stress and accelerated aging. Dr. Olivia I. Okereke and colleagues examined the chromosomes of 5,243 women aged 42 to 69 participating in the Nurses' Health Study. They found that women with phobic anxiety — irrational fears of anything from social situations to spiders — had shorter telomeres on their chromosomes.

Telomeres are DNA-protein complexes on the ends of chromosomes that are considered biological markers of aging. Shortened telomeres are thought to underlie many of the adverse health effects of aging, and perhaps even to contribute to looking older than one's years.

A pilot study published online by The Lancet Oncology last month underscored the benefits of limiting stress. Dr. Dean Ornish and colleagues at the Preventive Medicine Research Institute and the University of California, San Francisco, tested the effects of lifestyle changes on the length of telomeres.

Ten men were asked to make changes that included adopting a whole-foods plant-based diet, moderate exercise, stress management techniques (like yoga and meditation), and seeking greater intimacy and social support. After five years, changes in the length of their telomeres were compared with those among 25 men who were not asked to make such changes.

In the men who made lifestyle changes, telomere length increased by an average of 10 percent; the more changes the men made, the greater the increase in length. But telomere length decreased in the control group by an average of 3 percent.

Still, youthfulness is not just a question of biology. People are perceived to be younger than their years if they smile and laugh a lot (be proud of those laugh lines!) and are generally cheerful and upbeat, the kind of people who smile at strangers and wish them a good day.

I occasionally pass an older couple who walk together three times a week. With their dour expressions and grudging acknowledgment of my "good morning," I thought they were in their mid-90s. So one day I asked, only to learn that she was 80 and he was 83.

It also helps to pursue personal and professional activities you enjoy as you get older. My role models include the actress Estelle Parsons, who continues to perform on stage (and can do yoga headstands) at 85, and Dame Judi Dench, 78, who stars in movies despite having to learn her lines orally because macular degeneration has caused her vision to deteriorate.

My dear friend Margaret Shryer, 86, starred in a documentary about age discrimination and performed a one-woman show she wrote at a theater festival in Minneapolis this summer. Another friend, the award-winning broadcaster Lucy Jarvis, cane in hand at 96, still travels abroad to make television documentaries.

To my mind, it is far better to act young than to look young. Of course, it helps to be physically fit.

Too often, those who spend liberally to counter the superficial signs of age neglect their bodies below the neck and become physically old before their time. Muscle tissue inevitably declines with age, but much can be done to minimize and even reverse a loss of strength

Try using free weights or resistance machines. If these don't appeal, lift cans of soup (better for lifting than consuming) and continue to do chores that require strength, like digging in the garden or carrying groceries.

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Exxon to Extend Health Care to Married Same-Sex Couples

The Exxon Mobil Corporation, which has drawn much criticism for policies related to its gay and lesbian workers, said on Friday that it would extend health insurance and other employee benefits to married same-sex couples effective Oct. 1.

The move is an about-face for the company, which had defied pressure from human rights groups, pension funds and some of its own shareholders that had asked the company to protect gay and lesbian employees from discrimination in the United States. But Exxon Mobil's latest change of heart on same-sex benefits was not a result of soul-searching. Rather, the company said it was following the policies of the federal government, which, in recent months, has begun to issue rule changes and guidance on how gay couples should be treated in light of the Supreme Court's monumental decision in June to strike down the Defense of Marriage Act.

The decision found that legally married gay couples were entitled to the same federal benefits as straight couples.

Last week, the Labor Department, which oversees employer-based retirement, pension and health insurance plans, issued its own guidance: it said all legally married same-sex couples were entitled to the same protections as opposite-sex spouses. It's important to note that employers aren't required to provide medical spousal benefits at all. But if they do, the agency said that same-sex spouses should be treated equally.

The oil giant, whose benefits cover 77,000 workers and retirees in the United States, said it had always looked to national laws for guidance.

"Spousal eligibility in our U.S. benefit plans has been and continues to be governed by the federal definition of marriage and spouse," the company said in a statement. It also said that it provided benefits to same-sex spouses in 30 countries outside the United States.

Several federal agencies have begun to provide guidance on the practical implications of the highest court's ruling. Last month, for instance, the Internal Revenue Service said that same-sex couples would be considered married for federal tax law purposes, even if they live in a state that doesn't recognize their union.

The Labor Department law that governs many employee benefits, known as Erisa, or the Employee Retirement Income Security Act, does not oblige employers to extend health coverage to spouses.

And some experts note that there is no explicit law that prohibits companies from offering health benefits exclusively to opposite-sex spouses. But "it's in employers' interest to simply adopt one standard, recognizing all married couples for benefits, and avoid potential litigation," said Brian Moulton, legal director at the Human Rights Campaign, a group that works for equal rights for gay, lesbian, bisexual and transgender people.

Some legal experts say that Exxon's move could prompt other companies that must follow Erisa rules, but don't have same-sex benefits, to follow suit. Certain benefits protections must be applied to all spouses, gay and straight alike. If an employer offers a pension to its employees, for instance, all spouses are entitled to survivor benefits, explained Todd A. Solomon, a partner in the employee benefits practice group at McDermott Will & Emery and author of "Domestic Partner Benefits: An Employer's Guide."

Wal-Mart was another large company that did not offer domestic partner benefits, but it announced in August that it would begin extending coverage to both same-sex and opposite-sex domestic partners and same-sex spouses effective Jan. 1.

Exxon is facing a legal complaint in Illinois filed by Freedom to Work, a gay advocacy group, which claims the company discriminates based on sexual orientation. "Exxon is not the kind of company that voluntarily does the right thing," said Tico Almeida, president of the group. "They only do the right thing when the law requires them to."

Alan Jeffers, an Exxon spokesman, said the group's complaints were baseless and without merit. He also said the company had a "zero-tolerance policy" on all forms of discrimination, including sexual orientation.

In countries where it's mandated by law, Exxon does have policies barring discrimination against gay employees.

Exxon said in a statement that it "will recognize all legal marriages for the purposes of eligibility in U.S. benefit plans to ensure consistency for employees across the country."

But critics say their policies do little to protect the gay and lesbian employees here in the United States. Exxon Mobil ranks last in the Human Rights Campaign Corporate Equality index of the Fortune 1,000 corporations, with a score of negative 25 out of a possible 100. The low score stems from "not satisfying any of the criteria and actively resisting the shareholder resolutions to amend their nondiscrimination policy," said Deena Fidas, Human Rights Campaign's director for the workplace project.

Even when the Defense of Marriage Act was still the law of the land, many companies offered health benefits to its employees' same-sex partners and spouses anyway. Some employers even went as far as paying for the taxes that gay employees had to pay on the value of their partner's coverage (the tax no longer applies to gay married couples since the Defense of Marriage Act was ruled unconstitutional this summer).

According to the Human Rights Campaign, about 62 percent of the Fortune 500 companies offer domestic partner benefits. Exxon never extended the benefits to gay employees' domestic partners.

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Your Money: A Guide to the New Exchanges for Health Insurance

Given all of the rhetoric about the Obama administration's health care law, it's not surprising that many consumers are confused about how the new insurance exchanges will actually work. Some states that oppose the law have gone as far as intentionally limiting the information that trickles out to its residents.

But after much anticipation, the curtain will finally rise on the exchanges next week, providing millions of consumers with an online marketplace to compare health insurance plans and then buy the coverage on the spot.

The exchanges are likely to be most attractive to people who qualify for subsidized coverage. Individuals with low and moderate incomes may be eligible for a tax credit, which can be used right away, like a gift card, to reduce their monthly premiums. People with pre-existing conditions will no longer be denied coverage or charged more (this applies to most plans outside the exchanges, too). And all of the plans on the exchanges will be required to cover a list of essential services, from maternity care to mental health care.

"In today's individual market, it's like Swiss cheese coverage," said Sarah Dash, a research fellow at the Health Policy Institute at Georgetown University. "Consumers should have an easier time figuring out what they are getting for their money."

But it's still going to take some time to analyze the plans and their costs, which are expected to vary widely across the states. And the coverage may still pinch many families' budgets. Fortunately, there's a six-month window, from now to March 31, for people to figure it all out.

Here's some information to get you started:

Q. Where can I apply or get more information on the exchanges?

A. To avoid fraud artists, enter through the front door: Healthcare.gov. From there, you can find links to the exchange offered in your state. There may be technical glitches as the program gets started, so alternatively, you can call 1-800-318-2596.

Q. When does coverage go into effect?

A. You can apply as early as Oct. 1, but coverage won't begin until Jan. 1. The enrollment period for coverage in 2014 closes on March 31, 2014. After that, you can enroll only if you have a major life event like a job loss, birth, marriage or divorce.

Q. What sort of coverage will be offered?

A. All plans will have to provide the same set of essential benefits, including prescriptions, preventive care, doctor visits, emergency services and hospitalization (this also applies to most individual and small-employer group plans sold outside of the exchanges). But plans can offer additional benefits, or different numbers of services like physical therapy, so you'll need to do a side-by-side comparison to see what fits your needs — or at least the needs you can anticipate.

Q. Are the plans sold on the exchange more comprehensive than plans outside?

A. There are four plan levels, each named for a precious metal. They all generally offer the same essential benefits, but their cost structures vary. The lower the premium, the higher the out-of-pocket costs.

The bronze level plan, for instance, has the lowest premiums, but will require consumers to shoulder more costs out of pocket. They generally cover 60 percent of a typical population's out-of-pocket costs, and include deductibles, co-payments and coinsurance. The silver plans cover 70 percent; gold, 80 percent; while platinum covers 90 percent (and therefore carries the highest premiums).

If you buy a plan on an exchange, your annual out-of-pocket costs cannot exceed $6,350 for individuals and $12,700 for a family of two or more in 2014. Catastrophic plans are also available to people under age 30 or those suffering a financial hardship. These carry high deductibles (equivalent to the out-of-pocket maximum, or $6,350 for a single person, in 2014). You cannot apply tax credits to these plans, either.

Premiums will vary across the states because of a variety of factors, like market competition, the underlying cost of care and the negotiating power of the exchanges, according to Kaiser research.

Q. If the costs with plan levels are similar, how will plans differ within the metal levels?

A. Networks of doctors and hospitals will differ, and cost-sharing structures may also vary. One plan might have lower deductibles and higher co-pays, whereas another plan might have a separate deductible for prescriptions. Various medications may also be covered differently. "If you are someone who is taking medicines, make sure you know what your drugs will cost in the various plans being offered," said Cheryl Fish-Parcham, deputy director of health policy at Families USA, a Washington consumer advocacy group.

Q. Will I be eligible for a premium tax credit (subsidized coverage)?

A. People with income between 100 percent of the poverty line (or about $23,550 for a family of four) and 400 percent of poverty ($94,200 for a family of four) are eligible for a tax credit to defray premium costs. (All income eligibility is based on your modified adjusted gross income; the online version of this column links to a guide explaining how that is calculated).

The tax credits are set up so that consumers will not have to pay more than a certain percentage of their income, ranging from 2 percent for those with incomes of up to 133 percent of the poverty level ($15,282 for a single and $31,322 for a family of four) to 9.5 percent for those with income of 300 to 400 percent of the poverty level, according to the Center on Budget and Policy Priorities. The dollar amounts of the credits are calculated based on the costs of the second-to-lowest-cost silver plan available to you.

Kaiser has a calculator that can give you an idea of your eligibility.

Q. Can I get help with my out-of-pocket expenses, like deductibles?

A. People with incomes between 100 percent of the federal poverty line ($23,550 for a family of four) and 250 percent ($58,875 for a family of four) are also eligible for cost-sharing reductions, which means you'll pay less for items including deductibles and co-payments, and you'll have lower out-of-pocket maximums.

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Lacking Rules, Insurers Balk at Paying for Intensive Psychiatric Care

Christopher Capozziello for The New York Times

Cathy Morelli, right, with her daughter Melissa. Their insurer ultimately was forced to pay for the mental health care for Melissa that it initially denied.

THE first time Melissa Morelli was taken to the hospital, she was suicidal and cutting herself, her mother says. She was just 13, and she had been transferred to a psychiatric hospital, where she stayed for more than a week. Her doctors told her mother, Cathy Morelli, that it was not safe for Melissa to go home. But the family's health insurance carrier would not continue to pay for her to remain in the hospital.

The second time, the same thing happened. And the third and the fourth. Over the course of five months, Ms. Morelli took Melissa to the hospital roughly a dozen times, and each time the insurance company, Anthem Blue Cross, refused to pay for hospital care. "It was just a revolving door," Ms. Morelli said.

"You had not been getting better in a significant way," Anthem explained in one letter sent directly to Melissa, then 14, in July 2012. "It does not seem likely that doing the same thing will help you get better."

Desperate to get help for her daughter, Ms. Morelli sought the assistance of Connecticut state officials and an outside reviewer. She eventually won all her appeals, and Anthem was forced to pay for the care it initially denied. All told, Melissa spent nearly 10 months in a hospital; she is now at home. Anthem, which would not comment on Melissa's case, says its coverage decisions are based on medical evidence.

Melissa's treatment did not come cheap: it ultimately cost hundreds of thousands of dollars, Ms. Morelli said. Patients often find themselves at odds with health insurers, but the battles are perhaps nowhere so heated as with the treatment of serious mental illness.

It was not supposed to be this way. A federal law, the Mental Health Parity and Addiction Equity Act of 2008, was aimed at avoiding fights like this over coverage by making sure insurers would cover mental illnesses just as they cover treatment for diseases like cancer or multiple sclerosis.

Long a priority of Senator Edward M. Kennedy of Massachusetts, it was squeezed into a bank bailout bill with the help of Christopher J. Dodd, then a Democratic senator from Connecticut, after Mr. Kennedy learned that he had brain cancer, which turned out to be fatal. The law requires larger employer-based insurance plans to cover psychiatric illnesses and substance-abuse disorders in the same way they do other illnesses.

But five years after President George W. Bush signed the law, there is widespread agreement that it has fallen short of its goal of creating parity for mental health coverage.

As enrollment in coverage under the Affordable Care Act becomes available on Tuesday, the rules underlying mental health coverage in general — for both private insurers and the new health care exchanges — are still unclear, mental-health patient advocates say, leaving patients and families to grind through the process as best they can.

DECIDING how mental illness should be treated — and at what cost — is no easy matter. Unlike some physical ailments for which there are reams of studies suggesting a relatively clear standard of care, there is often little accepted medical evidence to support the range of treatments for many mental illnesses, like schizophrenia and severe depression.

"It's very different from the approach to a bypass procedure or a hip replacement," said Karen Ignagni, the C.E.O. of America's Health Insurance Plans, a trade association representing the nation's health insurers.

At issue is not coverage for run-of-the-mill care like prescription medications for depression or a few visits with a therapist. Insurers generally cover these costs the same way they cover medications for, say, high blood pressure.

But when patients need months of residential care, for example, or meetings with a therapist several times a week, insurers balk. The insurance executives say that the medical benefits of such treatments are not clear and that the industry is essentially being asked to write a blank check.

 Mental health accounts for a small part of total health care spending — by one estimate, $113 billion annually, or less than 6 percent of the $2.6 trillion overall health care bill. But pressure is intensifying on insurers under the Affordable Care Act, which includes mental heath care as an essential benefit, because they are already trying to keep the premiums they charge for plans on the new state marketplaces as low as possible. Insurers are concerned about the potential for new costs, while patient advocates worry that mental health will be neglected.

Both sides say Washington is partly to blame. The federal government has yet to write the mental health act's final regulations for insurance companies, leaving a crucial gap between the intent of the measure and how it actually works.

Senator Kennedy's son, Patrick J. Kennedy, the former congressman from Rhode Island who was one of the law's main backers, said he worried that the Obama administration had delayed the rules because officials were preoccupied with the president's broader legislation and needed the insurance companies' support.

President Obama "needs the private insurers to implement this law or it's not going to work," said Mr. Kennedy, who has talked openly about his struggles with depression and bipolar disorder. He has held hearings on mental health issues across the country to talk to patients and their families, including one earlier this year where Cathy Morelli spoke.

Insurance companies, for their part, say they would welcome final rules under the 2008 law.

"We think it may create better clarity," said a spokeswoman for Aetna, which says it fully supports the 2008 parity law.

This article has been revised to reflect the following correction:

Correction: September 28, 2013

An earlier version of this article misidentified the president who signed the Mental Health Parity and Addiction Act of 2008 into law.

It was George W. Bush, not Barack Obama.

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On the Threshold of Obamacare, Warily

The insurance marketplaces that form the centerpiece of President Obama's health care law are scheduled to open on Tuesday, a watershed moment for the Obama administration, but also a crucial turning point for millions of Americans who will finally get the chance to square the law's lofty ambitions with their own personal needs.

While some people desperate for coverage will need no persuading to sign up, for others the decision will amount to a series of complicated calculations that would challenge an accounting whiz, let alone an ordinary human: Are the new plans less expensive or more generous than existing ones? How do premiums and out-of-pocket costs compare? Are the networks of doctors and hospitals the most desirable? Who qualifies for how much of a subsidy, and what is the tax penalty for a miscalculation?

How millions of people answer these questions over the next six months will be vital to determining whether the Affordable Care Act lives up to its name and its ambitious goal of helping more people buy the coverage they need.

Much is at stake for insurers as well: they must attract enough healthy people to pay for the care of sicker patients and price their offerings to keep premiums low enough to be competitive but high enough to be sustainable.

Health insurance "is a very complex product," said Lynn Quincy, a senior health policy analyst for Consumers Union in Washington. "It is going to be more complex this time around because things are changing, and people are confused about the changes."

As the state insurance exchanges are set to open, we talked to people around the country who will be among the first to give them a test drive. For some, the law could provide welcome relief from mounting medical bills; for others, a break from rising premiums. Still others must decide whether insurance is right for them at all.

Michael Nagle for The New York Times

Mitchell McGovern works part time and has no health insurance.

Young and Healthy

Mitchell McGovern, 26, lives in Brooklyn and works as a part-time sales associate at a Crate and Barrel store in Manhattan. He earns about $15,000 a year and does not have health insurance of any kind.

A bout with pneumonia in January sent him to the doctor's office, which cost him $75, and $150 for medication. Mr. McGovern said he would love to buy health insurance — and he was mindful that the law requires him to do so — but only if it cost him less than $100 a month. "I live paycheck to paycheck," he explained.

Mr. McGovern is exactly the sort of person the Obama administration needs to enroll in the new insurance marketplaces if the federal health care law is to succeed — young, healthy people who until now have not been covered by insurance, either because they couldn't afford it or because it wasn't a priority. If a critical mass of these people doesn't enroll — the federal government hopes to sign up about 2.7 million of them — the premiums for plans offered on the exchanges could skyrocket and cause the market to fail as fewer and fewer people take part.

Mr. McGovern's current income will probably qualify him, just barely, for Medicaid in New York State. But for Mr. McGovern and others like him, predicting how much he will make even a few months from now is hard, and he may end up qualifying instead for tax-credit subsidies in the state marketplace. Mr. McGovern recently moved to New York from California and sees his job at Crate and Barrel as a foothold until he finds work that would offer more money and perhaps coverage paid largely by the employer.

His uncertain financial situation is typical of the population most likely to consider the insurance marketplaces, said Ceci Connolly, managing director of the Health Research Institute at PricewaterhouseCoopers. Only about 51 percent will have full-time jobs, with a median annual income of about $21,700, according to an analysis by her firm based on government data like the census. She said 38 percent of the people expected to enroll will end up shuttling several times between Medicaid and the marketplaces over the next four years.

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Exxon to Extend Health Care to Married Same-Sex Couples

The Exxon Mobil Corporation, which has drawn much criticism for policies related to its gay and lesbian workers, said on Friday that it would extend health insurance and other employee benefits to married same-sex couples effective Oct. 1.

The move is an about-face for the company, which had defied pressure from human rights groups, pension funds and some of its own shareholders that had asked the company to protect gay and lesbian employees from discrimination in the United States. But Exxon Mobil's latest change of heart on same-sex benefits was not a result of soul-searching. Rather, the company said it was following the policies of the federal government, which, in recent months, has begun to issue rule changes and guidance on how gay couples should be treated in light of the Supreme Court's monumental decision in June to strike down the Defense of Marriage Act.

The decision found that legally married gay couples were entitled to the same federal benefits as straight couples.

Last week, the Labor Department, which oversees employer-based retirement, pension and health insurance plans, issued its own guidance: it said all legally married same-sex couples were entitled to the same protections as opposite-sex spouses. It's important to note that employers aren't required to provide medical spousal benefits at all. But if they do, the agency said that same-sex spouses should be treated equally.

The oil giant, whose benefits cover 77,000 workers and retirees in the United States, said it had always looked to national laws for guidance.

"Spousal eligibility in our U.S. benefit plans has been and continues to be governed by the federal definition of marriage and spouse," the company said in a statement. It also said that it provided benefits to same-sex spouses in 30 countries outside the United States.

Several federal agencies have begun to provide guidance on the practical implications of the highest court's ruling. Last month, for instance, the Internal Revenue Service said that same-sex couples would be considered married for federal tax law purposes, even if they live in a state that doesn't recognize their union.

The Labor Department law that governs many employee benefits, known as Erisa, or the Employee Retirement Income Security Act, does not oblige employers to extend health coverage to spouses.

And some experts note that there is no explicit law that prohibits companies from offering health benefits exclusively to opposite-sex spouses. But "it's in employers' interest to simply adopt one standard, recognizing all married couples for benefits, and avoid potential litigation," said Brian Moulton, legal director at the Human Rights Campaign, a group that works for equal rights for gay, lesbian, bisexual and transgender people.

Some legal experts say that Exxon's move could prompt other companies that must follow Erisa rules, but don't have same-sex benefits, to follow suit. Certain benefits protections must be applied to all spouses, gay and straight alike. If an employer offers a pension to its employees, for instance, all spouses are entitled to survivor benefits, explained Todd A. Solomon, a partner in the employee benefits practice group at McDermott Will & Emery and author of "Domestic Partner Benefits: An Employer's Guide."

Wal-Mart was another large company that did not offer domestic partner benefits, but it announced in August that it would begin extending coverage to both same-sex and opposite-sex domestic partners and same-sex spouses effective Jan. 1.

Exxon is facing a legal complaint in Illinois filed by Freedom to Work, a gay advocacy group, which claims the company discriminates based on sexual orientation. "Exxon is not the kind of company that voluntarily does the right thing," said Tico Almeida, president of the group. "They only do the right thing when the law requires them to."

Alan Jeffers, an Exxon spokesman, said the group's complaints were baseless and without merit. He also said the company had a "zero-tolerance policy" on all forms of discrimination, including sexual orientation.

In countries where it's mandated by law, Exxon does have policies barring discrimination against gay employees.

Exxon said in a statement that it "will recognize all legal marriages for the purposes of eligibility in U.S. benefit plans to ensure consistency for employees across the country."

But critics say their policies do little to protect the gay and lesbian employees here in the United States. Exxon Mobil ranks last in the Human Rights Campaign Corporate Equality index of the Fortune 1,000 corporations, with a score of negative 25 out of a possible 100. The low score stems from "not satisfying any of the criteria and actively resisting the shareholder resolutions to amend their nondiscrimination policy," said Deena Fidas, Human Rights Campaign's director for the workplace project.

Even when the Defense of Marriage Act was still the law of the land, many companies offered health benefits to its employees' same-sex partners and spouses anyway. Some employers even went as far as paying for the taxes that gay employees had to pay on the value of their partner's coverage (the tax no longer applies to gay married couples since the Defense of Marriage Act was ruled unconstitutional this summer).

According to the Human Rights Campaign, about 62 percent of the Fortune 500 companies offer domestic partner benefits. Exxon never extended the benefits to gay employees' domestic partners.

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Well: Married Cancer Patients Live Longer

Married cancer patients live longer than single people who have the disease, suggesting that logistical and emotional support from a loved one may be far more critical to cancer care than previously recognized.

Numerous studies have suggested that married people have better overall health than single people, but those data likely are skewed by the fact that healthy people are more likely to have opportunities to marry. However, the latest study did not look at overall health, and instead focused on what happens to married and single people who become ill with cancer. The findings offer a glimpse into the crushing logistical burden that cancer treatments impose on patients, particularly those who are single.

"When you have a spouse who is present when the patient is diagnosed, they are an invested party and they are going to more than likely make sure the patient goes to the doctor, that they get the necessary treatments,'' said Dr. Ayal A. Aizer, chief resident of the Harvard Radiation Oncology Program and the study's first author. "We don't think there's something intrinsic about people who are married, but we do think it's the support marriage is providing that makes a difference."

Researchers from several institutions, including Harvard Medical School and the Dana-Farber Cancer Institute, analyzed nearly 735,000 people who received a cancer diagnosis between 2004 and 2008. The study, which used data from the National Cancer Institutes Surveillance, Epidemiology and End Results (SEER) Program, focused on the 10 leading cancer killers: lung, colon, breast, pancreatic, prostate, liver, non-Hodgkin lymphoma, head and neck, ovarian and esophageal cancers.

The study, published in The Journal of Clinical Oncology, found that single patients were 53 percent less likely to receive appropriate therapy than married patients. The finding suggests that maintaining grueling chemotherapy and radiation schedules and taking medication as prescribed is easier for people who have help from a spouse compared with single people who must manage the logistics of cancer treatment on their own.

Unmarried cancer patients also were 17 percent more likely to have late-stage cancer at the time of diagnosis, compared with married patients. That suggests that spouses play a role in encouraging patients to see a doctor, while single people may put off doctor visits, resulting in a more advanced cancer by the time they finally seek a diagnosis. Married patients were 20 percent less likely to die of their disease than single patients.

The data do not distinguish between same-sex and opposite-sex couples and don't account for patients who are engaged or living with a partner. Because some of the people labeled as single in the study probably have a committed partner, it's likely that the findings actually understate the scope of the problem for people who are truly coping with a cancer diagnosis on their own.

Notably, men with cancer showed a greater benefit from marriage than did women. That doesn't mean husbands are not supportive of wives, but instead suggests that single women do a better job of reaching out for social support than do single men, so the gap between single and married women with cancer is not as great as the gap between single and married men with cancer.

For doctors and hospitals, the data show that being single is an important risk factor for failing to comply with medical treatments, and cancer centers should focus on offering additional support to these patients, said Dr. Aizer. The study also offers a lesson for friends of people who have cancer, showing that small offers of help – like driving a patient to the doctor or offering to care for their children – can make a meaningful difference in a patient's survival.

"Cancer is a life changing diagnosis,'' said Dr. Aizer. "Patients have an enormous number of things to think about on top of what they do in their normal everyday life. It's really important that they have another invested party to help shoulder that burden."

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Tara Parker-Pope is the author of "For Better: The Science of a Good Marriage."

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This post has been revised to reflect the following correction:

Correction: September 27, 2013

An earlier version of this post misstated the name of an institution that some of the researchers are affiliated with. It is the Dana-Farber Cancer Institute, not the Dana Farber Cancer Center.

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Lacking Rules, Insurers Balk at Paying for Intensive Psychiatric Care

Christopher Capozziello for The New York Times

Cathy Morelli, right, with her daughter Melissa. Ms. Morelli's insurance company initially refused to pay for Melissa's hospital care.

THE first time Melissa Morelli was taken to the hospital, she was suicidal and cutting herself, her mother says. She was just 13, and she had been transferred to a psychiatric hospital, where she stayed for more than a week. Her doctors told her mother, Cathy Morelli, that it was not safe for Melissa to go home. But the family's health insurance carrier would not continue to pay for her to remain in the hospital.

The second time, the same thing happened. And the third and the fourth. Over the course of five months, Ms. Morelli took Melissa to the hospital roughly a dozen times, and each time the insurance company, Anthem Blue Cross, refused to pay for hospital care. "It was just a revolving door," Ms. Morelli said.

"You had not been getting better in a significant way," Anthem explained in one letter sent directly to Melissa, then 14, in July 2012. "It does not seem likely that doing the same thing will help you get better."

Desperate to get help for her daughter, Ms. Morelli sought the assistance of Connecticut state officials and an outside reviewer. She eventually won all her appeals, and Anthem was forced to pay for the care it initially denied. All told, Melissa spent nearly 10 months in a hospital; she is now at home. Anthem, which would not comment on Melissa's case, says its coverage decisions are based on medical evidence.

Melissa's treatment did not come cheap: it ultimately cost hundreds of thousands of dollars, Ms. Morelli said. Patients often find themselves at odds with health insurers, but the battles are perhaps nowhere so heated as with the treatment of serious mental illness.

It was not supposed to be this way. A federal law, the Mental Health Parity and Addiction Equity Act of 2008, was aimed at avoiding fights like this over coverage by making sure insurers would cover mental illnesses just as they cover treatment for diseases like cancer or multiple sclerosis.

Long a priority of Senator Edward M. Kennedy of Massachusetts, it was squeezed into a bank bailout bill with the help of Christopher J. Dodd, then a Democratic senator from Connecticut, after Mr. Kennedy learned that he had brain cancer, which turned out to be fatal. The law requires larger employer-based insurance plans to cover psychiatric illnesses and substance-abuse disorders in the same way they do other illnesses.

But five years after President Obama signed the law, there is widespread agreement that it has fallen short of its goal of creating parity for mental health coverage.

As enrollment in coverage under the Affordable Care Act becomes available on Tuesday, the rules underlying mental health coverage in general — for both private insurers and the new health care exchanges — are still unclear, mental-health patient advocates say, leaving patients and families to grind through the process as best they can.

DECIDING how mental illness should be treated — and at what cost — is no easy matter. Unlike some physical ailments for which there are reams of studies suggesting a relatively clear standard of care, there is often little accepted medical evidence to support the range of treatments for many mental illnesses, like schizophrenia and severe depression.

"It's very different from the approach to a bypass procedure or a hip replacement," said Karen Ignagni, the C.E.O. of America's Health Insurance Plans, a trade association representing the nation's health insurers.

At issue is not coverage for run-of-the-mill care like prescription medications for depression or a few visits with a therapist. Insurers generally cover these costs the same way they cover medications for, say, high blood pressure.

But when patients need months of residential care, for example, or meetings with a therapist several times a week, insurers balk. The insurance executives say that the medical benefits of such treatments are not clear and that the industry is essentially being asked to write a blank check.

 Mental health accounts for a small part of total health care spending — by one estimate, $113 billion annually, or less than 6 percent of the $2.6 trillion overall health care bill. But pressure is intensifying on insurers under the Affordable Care Act, which includes mental heath care as an essential benefit, because they are already trying to keep the premiums they charge for plans on the new state marketplaces as low as possible. Insurers are concerned about the potential for new costs, while patient advocates worry that mental health will be neglected.

Both sides say Washington is partly to blame. The federal government has yet to write the mental health act's final regulations for insurance companies, leaving a crucial gap between the intent of the measure and how it actually works.

Senator Kennedy's son, Patrick J. Kennedy, the former congressman from Rhode Island who was one of the law's main backers, said he worried that the Obama administration had delayed the rules because officials were preoccupied with the president's broader legislation and needed the insurance companies' support.

President Obama "needs the private insurers to implement this law or it's not going to work," said Mr. Kennedy, who has talked openly about his struggles with depression and bipolar disorder. He has held hearings on mental health issues across the country to talk to patients and their families, including one earlier this year where Cathy Morelli spoke.

Insurance companies, for their part, say they would welcome final rules under the 2008 law.

"We think it may create better clarity," said a spokeswoman for Aetna, which says it fully supports the 2008 parity law.

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Your Money: A Guide to the New Exchanges for Health Insurance

Given all of the rhetoric about the Obama administration's health care law, it's not surprising that many consumers are confused about how the new insurance exchanges will actually work. Some states that oppose the law have gone as far as intentionally limiting the information that trickles out to its residents.

But after much anticipation, the curtain will finally rise on the exchanges next week, providing millions of consumers with an online marketplace to compare health insurance plans and then buy the coverage on the spot.

The exchanges are likely to be most attractive to people who qualify for subsidized coverage. Individuals with low and moderate incomes may be eligible for a tax credit, which can be used right away, like a gift card, to reduce their monthly premiums. People with pre-existing conditions will no longer be denied coverage or charged more (this applies to most plans outside the exchanges, too). And all of the plans on the exchanges will be required to cover a list of essential services, from maternity care to mental health care.

"In today's individual market, it's like Swiss cheese coverage," said Sarah Dash, a research fellow at the Health Policy Institute at Georgetown University. "Consumers should have an easier time figuring out what they are getting for their money."

But it's still going to take some time to analyze the plans and their costs, which are expected to vary widely across the states. And the coverage may still pinch many families' budgets. Fortunately, there's a six-month window, from now to March 31, for people to figure it all out.

Here's some information to get you started:

Q. Where can I apply or get more information on the exchanges?

A. To avoid fraud artists, enter through the front door: Healthcare.gov. From there, you can find links to the exchange offered in your state. There may be technical glitches as the program gets started, so alternatively, you can call 1-800-318-2596.

Q. When does coverage go into effect?

A. You can apply as early as Oct. 1, but coverage won't begin until Jan. 1. The enrollment period for coverage in 2014 closes on March 31, 2014. After that, you can enroll only if you have a major life event like a job loss, birth, marriage or divorce.

Q. What sort of coverage will be offered?

A. All plans will have to provide the same set of essential benefits, including prescriptions, preventive care, doctor visits, emergency services and hospitalization (this also applies to most individual and small-employer group plans sold outside of the exchanges). But plans can offer additional benefits, or different numbers of services like physical therapy, so you'll need to do a side-by-side comparison to see what fits your needs — or at least the needs you can anticipate.

Q. Are the plans sold on the exchange more comprehensive than plans outside?

A. There are four plan levels, each named for a precious metal. They all generally offer the same essential benefits, but their cost structures vary. The lower the premium, the higher the out-of-pocket costs.

The bronze level plan, for instance, has the lowest premiums, but will require consumers to shoulder more costs out of pocket. They generally cover 60 percent of a typical population's out-of-pocket costs, and include deductibles, co-payments and coinsurance. The silver plans cover 70 percent; gold, 80 percent; while platinum covers 90 percent (and therefore carries the highest premiums).

If you buy a plan on an exchange, your annual out-of-pocket costs cannot exceed $6,350 for individuals and $12,700 for a family of two or more in 2014. Catastrophic plans are also available to people under age 30 or those suffering a financial hardship. These carry high deductibles (equivalent to the out-of-pocket maximum, or $6,350 for a single person, in 2014). You cannot apply tax credits to these plans, either.

Premiums will vary across the states because of a variety of factors, like market competition, the underlying cost of care and the negotiating power of the exchanges, according to Kaiser research.

Q. If the costs with plan levels are similar, how will plans differ within the metal levels?

A. Networks of doctors and hospitals will differ, and cost-sharing structures may also vary. One plan might have lower deductibles and higher co-pays, whereas another plan might have a separate deductible for prescriptions. Various medications may also be covered differently. "If you are someone who is taking medicines, make sure you know what your drugs will cost in the various plans being offered," said Cheryl Fish-Parcham, deputy director of health policy at Families USA, a Washington consumer advocacy group.

Q. Will I be eligible for a premium tax credit (subsidized coverage)?

A. People with income between 100 percent of the poverty line (or about $23,550 for a family of four) and 400 percent of poverty ($94,200 for a family of four) are eligible for a tax credit to defray premium costs. (All income eligibility is based on your modified adjusted gross income; the online version of this column links to a guide explaining how that is calculated).

The tax credits are set up so that consumers will not have to pay more than a certain percentage of their income, ranging from 2 percent for those with incomes of up to 133 percent of the poverty level ($15,282 for a single and $31,322 for a family of four) to 9.5 percent for those with income of 300 to 400 percent of the poverty level, according to the Center on Budget and Policy Priorities. The dollar amounts of the credits are calculated based on the costs of the second-to-lowest-cost silver plan available to you.

Kaiser has a calculator that can give you an idea of your eligibility.

Q. Can I get help with my out-of-pocket expenses, like deductibles?

A. People with incomes between 100 percent of the federal poverty line ($23,550 for a family of four) and 250 percent ($58,875 for a family of four) are also eligible for cost-sharing reductions, which means you'll pay less for items including deductibles and co-payments, and you'll have lower out-of-pocket maximums.

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Well: Statins Tied to Cataract Risk

In one of the largest studies ever done on the subject, researchers have found that taking statins, the widely used cholesterol-lowering drugs, is associated with an increased risk for cataracts. Previous studies had mixed results.

In the latest observational study, published online in JAMA Ophthalmology, scientists retrospectively examined 13,626 statin users and 32,623 nonusers, ages 30 to 85, who were part of a military health care system. The average length of statin use was about two years.

After adjusting for more than three dozen other health and behavioral variables, the scientists found that compared with nonusers, those who took statins had a 9 to 27 percent increased risk for cataracts.

Cataract development may be influenced by statins' effects on the oxidation process, the researchers say. The cholesterol-inhibiting properties of statins may also interfere with cell regeneration in the eye's lens, which requires cholesterol to maintain transparency.

"If a patient takes this medication because he is at high risk for heart disease, or already has heart disease, the proven benefit of statins is much greater than the suspected risk of cataracts," said the senior author, Dr. Ishak Mansi, a professor of medicine at the University of Texas. "But they have side effects, and doctors should not prescribe this medication lightly."

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Well: Living With Cancer: Feeling Older Than My Age

Sometimes cancer and its treatments make me feel as if I have entered a time machine that accelerates aging.

Several months ago I met a friend for a cup of tea and as we were paying, I caught sight of a stooped old lady across from me: no eyebrows on a pale face framed by thinning hair. A heartbeat later, the mirror image administered a shock. This crone belies my psychic age; that is, the age matching what I feel to be my authentic core identity. The little old lady looked about 85, whereas my psychic age hovers at a somewhat rebellious 16. My companion in the cafe, who copes with lung cancer, counseled me: "Important never to look in the mirror."

Don't get me wrong. I have always admired the spunky old ladies who teeter along upper Broadway with the aid of a companion or a walker. But they had a chance, I hope, to ease into their decrepitude gradually, whereas I seem to have jolted into mine in the prime of life. After three abdominal surgeries and three cycles of chemotherapy, a deeply cut gulf separates my little old lady self from the active 63-year-old before diagnosis.

Regardless of chronology, people in cancer treatment, even children, often look like we evolved from an antique race descended from Yoda: balding, shrunken, slow moving, greenish.

My little old lady self cannot bounce out of bed to start the day. Pills have to be doled out first. Instead of quickly throwing on appropriate clothes for the tasks at hand, my little old lady self places a comfortable uniform down on the bed — underwear, leggings, T-shirt, sweater, socks and thick-soled shoes — so she can sit down between the exertion of putting on each garment. The tasks at hand narrow to maintenance — grocery shopping, cooking, bills — instead of the teaching and mentoring and traveling of the past.

Before cancer, I felt the way Oliver Wendell Holmes did: "Old age is 15 years older than I am."

Now, though, a humbling acknowledgment permeates the atmosphere of little-old-lady-land: a realization that I cannot do what I used to do, a sense of being feeble or vulnerable, physically as well as mentally.

I must sit by the stove, waiting to turn off a boiling pot, or else I will forget and its contents will burn away along with the house. My computer passwords have to be reset repeatedly. Someone needs to drive me since my toes cramp up, making walking or accelerating and breaking perilous.

At various times, I have needed pharmaceutical products that arrived in large boxes. Bandages, bags, adhesives, latex gloves, syringes, surgical tape, gauze pads, antibiotics, salves, mouthwashes, drops, wipes and painkillers pile up in my closet so guests will not see them in the bathroom.

What an alter cocker — the Yiddish phrase for an old, complaining person — I have become.

"There is a difference between getting old and feeling old," my 17-years-older (non-Yiddish speaking) husband staunchly asserts. Desire stands him in good stead.

"Getting old means knowing you can't stay up late at a party or run a mile," he says. "Feeling old means you don't want to stay up late at a party or run a mile. We're not in an assisted care unit yet," he smiles, "or visited weekly by home health care nurses!"

"You got old before you felt old," I respond, hugging him. "I felt old before I got old."

Wanting to do what he can't do oddly cheers him. But as the time machine curiously slows me down while it accelerates my aging, I try to savor doing what I didn't do when I was an ambitious middle-aged professional.

These days I can sit still and listen—not advise or judge but listen — to my daughters and step-daughters. I'm grateful for the opportunity my grandchildren give me to hang out: a different pleasure with the 13-year-old (we play electronic games), the 7-year-old (he reads aloud to me) and the baby (who grins and gurgles while I hug and sing).

There is another silver lining, even for a psychic adolescent. As I become my husband's contemporary, we remain soul mates, even though (or maybe because) his psychic age is 11. So occasionally I still get to boss him around.

Or is that notion just one of my teen dreams?

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Phys Ed: Why Runners Don’t Get Knee Arthritis

Phys Ed

Gretchen Reynolds on the science of fitness.

One of the most entrenched beliefs about running, at least among nonrunners, is that it causes arthritis and ruins knees. But a nifty new study finds that this idea is a myth and distance running is unlikely to contribute to the development of arthritis, precisely and paradoxically because it involves so much running.

It's easy to understand, of course, why running is thought to harm the knee joint, since with every stride, ballistic forces move through a runner's knee. Common sense would suggest that repeatedly applying such loads to a joint should eventually degrade its protective cartilage, leading to arthritis.

But many of the available, long-term studies of runners show that, as long as knees are healthy to start with, running does not substantially increase the risk of developing arthritis, even if someone jogs into middle age and beyond. An impressively large cross-sectional study of almost 75,000 runners published in July, for instance, found "no evidence that running increases the risk of osteoarthritis, including participation in marathons." The runners in the study, in fact, had less overall risk of developing arthritis than people who were less active.

But how running can combine high impacts with a low risk for arthritis has been mysterious. So for a new study helpfully entitled, "Why Don't Most Runners Get Knee Osteoarthritis?" researchers at Queen's University in Kingston, Ontario, and other institutions looked more closely at what happens, biomechanically, when we run and how those actions compare with walking.

Walking is widely considered a low-impact activity, unlikely to contribute much to the onset or progression of knee arthritis. Many physicians recommend walking for their older patients, in order to mitigate weight gain and stave off creaky knees.

But prior to the new study, which was published last week in Medicine & Science in Sports & Exercise, scientists had not directly compared the loads applied to people's knees during running and walking over a given distance.

To do so now, the researchers first recruited 14 healthy adult recreational runners, half of them women, with no history of knee problems. They then taped reflective markers to the volunteers' arms and legs for motion capture purposes, and asked them to remove their shoes and walk five times at a comfortable pace along a runway approximately 50 feet long. The volunteers likewise ran along the same course five times at about their usual training pace.

The runway was equipped with specialized motion-capture cameras and pads that measured the forces generated when each volunteer struck the ground.

The researchers used the data gathered from the runway to determine how much force the men and women created while walking and running, as well as how often that force occurred and for how long.

It turned out, to no one's surprise, that running produced pounding. In general, the volunteers hit the ground with about eight times their body weight while running, which was about three times as much force as during walking.

But they struck the ground less often while running, for the simple reason that their strides were longer. As a result, they required fewer steps to cover the same distance when running versus walking.

The runners also experienced any pounding for a shorter period of time than when they walked, because their foot was in contact with the ground more briefly with each stride.

The net result of these differences, the researchers found, was that the amount of force moving through a volunteer's knees over any given distance was equivalent, whether they ran or walked. A runner generated more pounding with each stride, but took fewer strides than a walker, so over the course of, say, a mile, the overall load on the knees was about the same.

This finding provides a persuasive biomechanical explanation for why so few runners develop knee arthritis, said Ross Miller, now an assistant professor of kinesiology at the University of Maryland, who led the study. Measured over a particular distance, "running and walking are essentially indistinguishable," in terms of the wear and tear they may inflict on knees.

In fact, Dr. Miller said, the study's results intimate that running potentially could be beneficial against arthritis.

"There's some evidence" from earlier studies "that cartilage likes cyclical loading," he said, meaning activity in which force is applied to the joint, removed and then applied again. In animal studies, such cyclical loading prompts cartilage cells to divide and replenish the tissue, he said, while noncyclical loading, or the continued application of force, with little on-and-off pulsation, can overload the cartilage, and cause more cells to die than are replaced.

"But that's speculation," Dr. Miller said. His study was not designed to examine whether running could actually prevent arthritis but only why it does not more frequently cause it.

The results also are not an endorsement of running for knee health, he said. Runners frequently succumb to knee injuries unrelated to arthritis, he said, and his study does not address or explain that situation. One such ailment is patellofemoral pain syndrome, which is often called "runner's knee."

But for those of us who are — or hope to be — still hitting the pavement and trails in our twilight years, the results are soothing. "It does seem to be a myth," Dr. Miller said, that our knees necessarily will wear out if we continue to run.

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Well: Ask Well: Is It Safe to Eat Soy?

A

Soy has been a dietary staple in Asia for many centuries. Some studies have found that it may offer some cardiovascular benefits, though the evidence at this point is more suggestive than conclusive.

As far as any downside, most of the health concerns about soy stem from its concentration of phytoestrogens, a group of natural compounds that resemble estrogen chemically. Some experts have questioned whether soy might lower testosterone levels in men and cause problems for women who have estrogen-sensitive breast cancers. Animal studies have found, for example, that large doses of phytoestrogens can fuel the growth of tumors.

But phytoestrogens mimic estrogen only very weakly. A number of clinical studies in men have cast doubt on the notion that eating soy influences testosterone levels to any noticeable extent. And most large studies of soy intake and breast cancer rates in women have not found that it causes any harm, said Dr. Anna H. Wu of the Keck School of Medicine at the University of Southern California. In fact, work by Dr. Wu and others has found that women who consume the equivalent of about one to two servings of soy daily have a reduced risk of receiving a diagnosis of breast cancer and of its recurrence.

Still, some women who have developed breast cancer remain particularly worried about eating soy. But the evidence "is overwhelming that it's safe," said Dr. Bette Caan of the Kaiser Permanente Northern California Division of Research, who has studied soy intake and breast cancer. "If people enjoy soy as a regular part of their diet," she said, "there's no reason to stop."

Last year, in its nutrition guidelines for cancer survivors, the American Cancer Society noted that eating traditional soy foods — like tofu, miso, tempeh and soy milk — may help lower the risk of breast, prostate and other cancers. But the guidelines do not recommend soy supplements, which tend to be highly processed and not very rigorously tested.

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Roll Over? Fat Chance

By Poh Si Teng

Tony Cenicola/The New York Times

Doggie Weight Watchers: With waistlines expanding, some chubby dogs are being sent to fitness programs to get slim and trim.

She has been in at least three fitness programs. She runs on the treadmill. She swims in a lap pool. Her trainers shout encouragement. And although her target weight still eludes her, Lolita remains optimistic, smiling gamely during her workout and snacking on carrots.

If only her legs weren't so short.

Lolita is a 4-year-old dachshund, a breed that like the beagle and Labrador retriever is prone to putting on extra pounds. In her case, about eight pounds too many.

But the problem of overweight dogs cuts across breeds. More than half of American dogs are overweight, according to the Association for Pet Obesity Prevention, an organization founded by a veterinarian to draw attention to the problem. And in dogs, as in people, extra weight is linked to diabetes, arthritis and high blood pressure as well as kidney and respiratory diseases.

Reducing calorie intake is part of the solution, veterinarians and pet behaviorists say. But diet without exercise isn't enough. So dogs have been hitting the gym for fitness programs at kennels and pet spas around the country.

At the Morris Animal Inn in Morristown, N.J., where Lolita works out, the pools and treadmills are part of a 25,000-square-foot building surrounded by nature trails. Staff members in khakis and polo shirts lead dogs through exercises and reward them with yogurt vegetable parfaits.

Some of the fitness programs are tied to events like the Kentucky Derby (in the canine version, dogs jump over hay bales) and holidays (New Year's Resolution Camp is popular). Programs range from the Olympian, at a daily rate of about $100, to the Athlete, at about $40 a day.

But even a luxury spa environment can't mask the hard work of working out. For Abbe, a 6-year-old yellow Labrador retriever who is about 20 pounds overweight, a short tussle with a toy leaves her panting. She does better retrieving a ball from an indoor pool, a task that continues to engage her after three dozen tosses. "The will is so there," said Lisa Tims, her trainer at the Morris Animal Inn, as Abbe swam to get the ball before lumbering out of the water.

Cesar Millan, the popular dog trainer whose books and television shows promote a philosophy of "exercise, discipline, affection," said most dogs were overweight because of lazy owners who confuse food with affection and attention. Letting the dogs out in the backyard is no substitute for a walk, he added. And giving the dog a cookie doesn't make up for not playing with him.

"Dogs today have butlers and maids," Mr. Millan said. "They don't hunt for their food anymore, but they should work for food." And that work needs to include walks during which the dog is focused on obeying commands to be physically and mentally engaged.

For the last seven years, the University of Tennessee College of Veterinary Medicine has offered a fat camp for dogs, inpatient and outpatient. But the dogs who live at the clinic tend to be more successful, said Dr. Angela Witzel, a veterinarian at the university who specializes in animal nutrition. "A dog can give me big puppy-dog eyes, and I'm still not going to give him a piece of chicken," Dr. Witzel said, whereas an owner may not be able to resist the appeal.

In choosing dog food, she recommended checking the label on store-bought food for the endorsement of the Association of American Feed Control Officials, an organization that helps develops nutritional standards for animal food.

And "if you are going to use a homemade dog food, consult a veterinarian," Dr. Witzel said, because different dogs have different nutritional needs. "For instance, a dog doesn't need carbohydrates unless she is pregnant or lactating."

Lisa Walsh, the owner of Loyalville, a kennel and training center in Hatchbend, Fla., estimated that two-thirds of her canine clients were overweight when they arrived. She cited inactivity and foods high in carbohydrates as causes. To solve the problem, Ms. Walsh offers one-on-one, 24-hour care and training at $1,250 a month.

She advocates a diet that includes what she called "the prey model" of raw, meaty bones and organs. "It's going to gross some people out," she said, "but the ideal meal would be a whole rabbit. Or a whole squirrel for a fox terrier." (For squeamish owners, Ms. Walsh recommended serving dogs dehydrated or frozen raw-food diets; raw chicken is another option.)

Indigo Ranch in Vernonia, Ore., is a kennel that offers what it calls a doggy fat camp. The camp began about two years ago, shortly after a county shelter contacted Indigo Rescue, the nonprofit rescue organization financed by Indigo Ranch, about a 3-year-old Lab aptly named Butters. At 142 pounds, he was considered unadoptable and was about to be euthanized, said Heather Hines, the director of Indigo Ranch.

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Turkish Protesters Are Still Said to Be Ailing From Tear Gas

ISTANBUL — Almost 40 percent of protesters surveyed by a Turkish medical group complained of continuing repercussions from their exposure to the tear gas that security forces used to quell last spring's antigovernment demonstrations, the group says.

In a report released last week, the Turkish Medical Association, based in Ankara, the capital, said it had questioned more than 11,000 protesters nationwide who were exposed to tear gas for up to eight hours a day over multiple days during the protests, which convulsed Turkey for weeks in June. It said 39 percent complained about continuing effects from the exposure, with 14 percent saying they suffered skin irritations and 10 percent reporting dizziness and balance problems.

The government has strongly criticized the medical association, saying it is biased because its members — doctors, nurses and medical students — treated the wounded. During the protests, riot police officers detained dozens of doctors and other medical workers on charges of violating the public order.

The large protests grew out of more modest demonstrations in late May over the government's plans to raze Gezi Park in Istanbul to build a shopping mall, and left five people dead and thousands injured. The riot police used tear gas, rubber bullets and water cannons liberally, and Prime Minister Recep Tayyip Erdogan was widely criticized for the harshness of the crackdown.

Separately, Physicians for Human Rights, a New York-based organization, released a report Wednesday that said Turkish security forces used tear gas on a large scale and targeted medical facilities during the demonstrations.

"The level and type of force used by Turkish authorities against peaceful protesters during the Gezi Park demonstrations, as well as the targeting of doctors who courageously treated them, was unnecessary and inexcusable," Dr. Vincent Iacopino, the senior medical adviser to Physicians for Human Rights and the report's co-author, said in a statement. "The use of all tear gas in Turkey must be banned, and government authorities must ensure these rampant abuses are never repeated."

The report said 11 lost their eyes after tear-gas canisters were fired directly at their faces.

The protests, which spread to more than 60 cities, moved beyond civil unrest to become an unprecedented outcry against the more than 10-year leadership of Mr. Erdogan and his pro-Islamic government, which demonstrators said had adopted authoritarian tactics. Mr. Erdogan dismissed the criticisms and said the protests were the work of extremists and international interest groups, whom he would not identify, that are trying to overthrow the government.

President Abdullah Gul, in a speech on Tuesday in New York, where he attended the opening of the United Nations General Assembly, praised environmental concerns that set off the protests but said the New York police would have responded the same way had protesters shut down the city center.

The Ministry of Health submitted a draft bill in July that seeks to criminalize certain provisions of emergency medical care, levying severe penalties on any medical worker who assists the wounded without official authorization, said Ali Cerkezoglu, the general secretary of the Istanbul Medical Association.

"By this draft law, the government treats any ad hoc clinic or medical assistance as a crime to be penalized by imprisonment and heavy fines," Mr. Cerkezoglu said. "If it becomes law, medical service, even an emergency situation in the street, would be controlled by the government." The proposal is expected to be debated when Parliament reconvenes next month.

Health Ministry inspectors interrogated several members of the Istanbul Medical Association about the care they provided during the Gezi Park protests, Mr. Cerkezoglu said.

The Physicians for Human Rights report, based on reviews of physical and psychological data on 169 victims, concluded that almost all were exposed to tear gas and experienced multiple symptoms, including respiratory problems, skin rashes, hearing loss, high blood pressure and allergic reactions. The report also included interviews with 53 victims and witnesses that members of the group conducted in Istanbul and Ankara from June 25 to July 2.

Turkish security forces reportedly used 130,000 cartridges of tear gas in just 20 days following the outbreak of the protests, nearly draining the country's entire yearly supply. Some news reports said the army's stocks were used as replenishment.

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