Under the Affordable Care Act, preventive medicine is to be made a higher priority. Why should this make a difference? Well, if the physicians catch illnesses, diseases and disorders early enough, treatment is quick and cheap and, more often than not, very effective in curing us. If we delay until the symptoms are just too bad to ignore, this means treatment will be more expensive and there may already have been damage which will leave us with chronic problems. Now think about the costs. Because of the early intervention, the insurance company saved money and you had a better quality of life. If this was the general experience, the cost of healthcare would fall. The premium rates would fall. You would be happy. This is the norm in Europe. Why is this not the standard model for us? The answer is the opposition of the medical community. They have invested capital in building ever larger hospitals and clinics. People only use these facilities when they are more seriously ill. The longer the period of treatment, the more money the doctors and their employers make. So the medical community has a direct financial interest in seeing us get more ill and stay ill longer. That’s where all their profit comes from.

Let’s take two simple examples to see how preventive medicine can help. In a recent survey, 85% of the adult population recognized the importance of vision health. This is not, you understand, just about deciding whether you need a new prescription for spectacles or contacts. In the same survey, 89% of participants knew the eye exam also detects chronic diseases like diabetes. So, if you were to have your eyes tested once a year, the early signs of diabetes would be identified and, with changes to your diet, you could avoid the need for dependence on insulin injections for the rest of your life (it also avoids the cost of the treatment). Following the European model, registered nurses are now being licensed to reach out to people in the community to monitor for symptoms of diabetes and manage the problem if diagnosed. This is a big cost saving and, if this was applied to other problems, it would save on cost and time because the treatment comes to you — it would bring cheap health insurance nearer as well. So when you are thinking about your individual health insurance plan, pay particular attention to preventive care. It can save you time and money.

Come September 2012, this is due to change a little thanks to the Affordable Care Act — that’s the Obamacare law the GOP love to hate and we consumers should be learning to love. Look at any website or blog that talks about insurance and you will always see the advice to shop around. Compare and contrast are the key words. Except the language the insurers use makes this quite difficult. New regulations published by the Department of Health and Human Services will require corporations selling health cover to describe their plans in language we can all understand. There must be clear summary statements about what each plan does and does not cover, what exceptions or limitations will apply when it comes to getting treatment, and more precisely how much it will cost. Not surprisingly, the insurers are distressed because this will mean rewriting all their marketing material so that ordinary people can compare one plan with another. Announcing these new rules, Kathleen Sebelius hoped we consumers would see an immediate benefit. Well, hope springs eternal and the marketing people are no doubt working away to craft new words that will say as little as possible.

To make it easier to enforce the rules, each insurer must produce a Summary of Benefits and Coverage (SBC) for each plan. This must be backed up by a glossary of definitions so that all the complicated words the insurers like to use are explained. This must be easily understood by everyone including those who do not have English as their first language. So when you are thinking about buying or coming up to renewal, you must be given an SBC as a standardized comparison tool. Think when you go into a store to shop for food, there are standard labels on the packaging giving you Nutrition Facts. The same will apply to health plans with the insurer required to give you details of the treatment options for basic situations, e.g. managing a chronic condition like diabetes, having a baby, and so on. So, as from September, it should be easier to shop around for an individual health insurance plan. If you receive old material that’s hard to understand, complain to your local Insurance Commissioner. If we all stand together, we will get better information with our health insurance quotes and renewal notices.

Enter the copayment coupons. The idea of copayments has been central to insurance policies for some years. This requires the patient to pay a proportion of the medical costs. It is actually self-insurance of that part of the costs. The justification advanced by insurance companies is that it reduces moral hazard, i.e. it is an encouragement to people only to seek treatment when it is genuinely necessary. Through the coupons, the manufacturers offer a form of subsidy to the patients if they copay for branded drugs. This makes the branded drugs more affordable and maintains more of their profit margin. Obviously, if the brands were losing too much of their market share, the manufacturers would have to reduce their prices to compete with the generics. In theory, the coupons represent a compromise. The patients pay less for the brand, but more than for the generic. The manufacturers give away a part of their profits, but less than through a price reduction to complete with the generic directly.

There is now a class action effectively accusing the manufacturers of fraud through their use of these coupons. As it stands, the insurance companies pay the manufacturer a fixed price for every branded pill or tablet prescribed. The manufacturers and pharmacists have been forgetting to tell the insurers about the coupons. It is highly relevant that the patients have been paying less at the drugstore counters. Because there are no savings to the insurance companies in paying for the generics, the premium rates stay high. This makes cheap health insurance even less likely to appear. In reality everyone is losing. Customers are still paying more than they should. Both individual and group health insurance plans cost more than they should. All this being purely for the benefit of the pharmaceutical industry. The class action describes these coupons as part of a bait and switch scam. If the courts agree, heavy damages will be awarded and there will be compensation available to some consumers.

Put another way, the advances in medical science are causing significant losses to the insurance industry. It is another of those sad facts of life that medical care does not come cheap. Indeed, the cost of treatment has been rising significantly faster than inflation for the last ten years. The result is one of these unfortunate ironies. Physicians and their employers, whether hospitals or clinics, are able to continue to levy high-dependency care billing over long periods of time simply because the physicians can now keep the patients alive. This places often intolerable financial burdens on the families without insurance. Bankruptcy is quite common. Once the hospitals or clinics know there is an insurance policy in place, the bills can continue. Insurance companies have very deep pockets. In this, the actual quality of life “enjoyed” by the patients is ignored. The sole question of interest is whether life persists.

Starting in 2010, large insurers began to withdrawn from the market, refusing to sell individual health plans. For now, the majority are still selling group plans because the risk is spread more evenly among members of the group. But with the investment returns being so poor, insurance companies are beginning to question whether even group cover is economic. So, if you want to look into the future, it may be a sound financial move to buy a long-term care policy now. There are still some insurers offering individual cover. If you are still relatively young, you are likely to need long-term care as you age. This will keep the relative premium rate low. But if you delay, the chances are that none of the larger, more financially stable insurers will offer individual health insurance including long-term care. Of course, some insurers are likely to continue long-term care through group health insurance plans. Except, many employers have been reviewing their remuneration packages and some have been cutting back on benefits. The fact that long-term care may be included today does not mean it will still be there tomorrow.

The problem for doctors is the issue of patient confidentiality. It is entirely possible the complainer has been diagnosed with a mental illness or there is a perfectly satisfactory way of showing why the complaint is not justifiable. But replying is usually impossible without breaching confidentiality about the diagnosis or treatment. The result is reputations are damaged and income falls as people cancel appointments and seek treatment from other doctors. There is no remedy against the sites where these negative reviews appear. They are protected by Section 230 of the Communications Decency Act. So the new strategy is to go after the patients.

This is a two-pronged approach. First, the attorney gets details of the poster from the site and threatens to sue the individual for defamation. The second is to cut this off at source by requiring patients to sign a non-disclosure agreement (or gagging contract) which bars the publication of any criticism online or through electronic platforms. This distinguishes the casual opinion of, say, a restaurant meal or the extent of leaks after a plumber claims to have finished, from the more expert services delivered by a doctor or dentist. It is less easy for a lay person to say whether a diagnosis is correct or a treatment appropriate.

The battle is not one-sided. RateMD posts a warning against the names of all the doctors who use gagging clauses and Yelp refers posters to attorneys specializing in free speech if a doctor or dentist threatens legal action. In reality, it is unlikely a court would hold these terms binding, but they are already chilling free speech. One of the more interesting reactions has come from the companies providing health insurance plans. They have been silent despite the highly public debate criticizing the medical professional. This is not to say insurers should police the contracts between physicians, dentists and their patients. But the insurers do have a say, particularly if a primary care physician refuses to deal with patients because they would not accept a gagging contract. Health insurance plans should ensure easy access to medical care.

In many cases, this represents double billing. Some is gouging. So here comes the big issue. No one walks around wearing badges declaring whether they are in your network. There’s no way you could tell and, even if you were conscious and aware of the risks, there’s no obligation on anyone to tell you whether they are in your plan. The problem is getting worse because more specialists now restrict themselves to a 9-to-5 day. Finding a networked specialist at night is a real challenge. From the insurer’s point of view, the only obligation is to pay the network charges agreed before you have treatment. If a network surgeon asks for an anesthetist, he or she has no duty to ensure the person who knocks you out is inside the network. Fortunately, it is reasonably common to find an obligation for an HMO to pay all the costs when you have a medical emergency or there is no physician available from the network. But PPOs often do not have the same rules and it is more common for members to be surprised by out-of-network bills.

Although this may not be a problem you can deal with as a patient, this is something you should address as a parent should your child be the patient or your partner, parent or some other close relative is the one going through treatment. To avoid the recovery period being blighted by the arrival of bills and then the threats of collection agencies, talk with the hospital or clinic at every point when new people are to be introduced to the case. Ask for confirmation each new healthcare professional is within the network specified by the group or individual health insurance plan. You may well rapidly become the most unpopular person in the hospital, but unless you address the issue at source, you may well find your health insurance provider refuses to pay. For the record, this is the most common complaint made to Insurance Commissioners around the country.

So let’s switch to the other end of the activity scale and see what problems emerge. The ERs around the country fill up with sports injuries. This can be something relatively minor like a simple sprain or strain, or it can be broken bones, or more serious damage likely to cause long-term problems. The more people practice or train, the more they repeat the same muscular actions and this can cause serious strain injuries. The ones most at risk are those who train for endurance events like the marathon. Despite the fact the news media cover people dying while running in marathons, triathlons and other distance events, a remarkable number of people now enter these events. Some are doing it for “fun”. Others take a more professional approach. Some new research followed forty athletes training for endurance events, giving regular MRI scans. The results showed the majority were stretching their heart muscles, in five cases risking permanent damage. These five had been training for longer than the others with signs of scarring to the tissue within the right ventricle.

As with all research, it’s necessary to keep everything in context. There’s no evidence of training being dangerous for the average person. Indeed, within moderation, exercise is good for you. But if you take on a commitment based on training more than twenty hours a week, you are moving on to the other side of the scale where you are risking injury simply by continuing to train. For the record, the five athletes with heart damage were training ten hours a day which is excessive. The moral for you as an average person is not to start an activity at your maximum. Build up slowly, getting fitter and developing muscle tone before pushing yourself too hard. In this way, you will sail through any medical examination to get your group or individual health insurance. Thereafter, if you do decide to train hard for an endurance event, get regular medical checkups to ensure you do not damage yourself and to reduce the risk of your health insurance plan being cancelled.

Standing back for a moment, there’s a universal truth underlying all health plans and their economics. If this was a perfect world, we would all earn the lowest premium rates by living and working in a completely accident-free zone. We would never meet anyone else with a contagious or infectious disease so we would never fall ill. Our medical history would show all our family members lived to the average life expectancy without any major health problems and needing no long-term care. And just to show we mean to follow in the family tradition, we do not drink, smoke, eat an unhealthy diet or do anything dangerous like climbing mountains or practicing parkour. Unfortunately, it’s impossible to organize your life in this way. Unless you have your own bubble to protect you as you meet other people, and never drive to and from work, you are always likely to catch the latest bugs and get into accidents. That said, the range of plans on offer from the FEHBP is genuinely impressive.

If you are considering a job with the federal government or you are already employed, here are a few quick pointers that will also help others asked to choose between several competing plans. Remember the point of any insurance is to protect you against the worst possible situations. So, instead of looking at how each of the plans responds to the routine medical problems, consider what would happen should you suffer catastrophic injury or run into a chronic disease like cancer. The key factor is how much you would have to pay out of your own pocket in such situations. Beware the high deductibles in policies including the serious injuries and chronic diseases. Now look at whether there are plans allowing you to claim tax benefits. Some savings account plans and Flexible Spending Accounts give a tax break and allow the money saved to be used in ways not always available under the conventional health plan.

Finally, look at what will happen at retirement. Under FEHBR, you must be a member of the plan for at least five years before you can take any of the plans into retirement. Think very carefully about the family plan. Should you die before you take out this plan, your spouse will have no cover. The rules of every group health insurance plan are different on issues such as this. This means not only taking care when deciding what plan to accept when taking up the first job, but also reviewing the plan as you age. Group health insurance is always good value but, with care, it can be the best.

Ignoring the usual politics and second-guessing what the Supreme Court will rule in 2012, let’s focus on what will happen between now and 2014 when the whole Act’s program is supposed to be in force. If you are a one-person business, you will be caught by the mandate just like any other individual. That means you buy cover or pay a penalty. For the record, the penalty is $695 or 2.5% of your income whichever is the greater unless the actual cost of the premium will be more than 8% of your income. You do the math to weigh up where you interests lie.

There’s no mandate for businesses, but there are penalties for failing to put a plan in place. If you have up to 25 employees, there’s a tax break to set off against half the cost of group cover. But you only get the maximum benefit if you are really small, i.e. you do not have the equivalent of 10 full-time employees and the average of their pay is less than $25,000. Your right to the tax break reduces as your size and the average pay increases. If you are small but your employees earn an average of $50,000 or more you lose the tax credit. In 2014 every state should have a Small Business Exchange in operation and, if you decide to buy through your local exchange, the tax credit will increase. However, these tax credits are only to prime the pump. Once you have a plan for your business, the credit will phase out over five years and only for two years after the exchanges are running.

The penalties can be quite significant and you cannot avoid them simply by buying really cheap health insurance. Whatever group plan you buy has to offer a minimum set of benefits. If this persuades you to spend too much you could get caught by an “affordability” test. The premium rate charged to an employee cannot exceed 9.5% of the family’s income. So when you are looking for group health plans for your employees or reviewing the current plan, remember the tax breaks now available and, more importantly, remember how the penalties will be calculated come 2014. Indeed, if you run a small business, you could find it beneficial to talk through all these issues with your accountant and insurance agent. If the Affordable Care Act survives the Supreme Court challenge, you will have to deal with the threat of penalties.

The Association of American Medical Colleges estimates that, by 2020, we will be short about 90,000 doctors. As if his was not a serious enough problem, the reality is significantly worse in some states. If you are lucky enough to live in the northeastern states, there’s a good ratio of doctors per 100,000 population. Put the other way round, Mississippi has less than half the number of doctors practicing in Massachusetts. This reflects capitalism at work. There are more wealthy people to treat in Massachusetts. Doctors go where they can make the most money. Putting profit to one side, it’s always been more difficult to persuade doctors to work in rural states. As an example, Texas released 1,200 trained doctors from college last year. This is the second highest number of graduates in the US but Texas has one of the lowest numbers of doctors per head of population, i.e. assuming most newly qualified doctors stay in the state where they graduate, Texas is failing to train enough doctors. Were it not for the foreign-trained doctors, the shortage in Texas would be a crisis — another reason for allowing more immigration.

We need to see a major culture change with double the current medical colleges training thousands more doctors. Since some are deterred from practice by the cost of insurance, there’s a need to look again at the laws on medical negligence and medical malpractice. If the maximum number of people are to be encouraged into the profession, pay and conditions must encourage people to move into states where there’s already a dangerous shortage. Unless this happens, enlarging the number of people with health insurance plans will just produce frustration as they realize there are not enough physicians to treat them. So before you buy individual health insurance, ensure there are enough doctors to treat you in your state.