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.

There are several key issues about the performance of Insurance Commissioners even where they do have powers to approve rate increases. The problem may be simply put. The way the actuaries calculate each company’s rates is highly complicated. More importantly, there are often assumptions made based on data not made available to the Commissioners. Insurers usually argue their own data is commercially sensitive and not to be disclosed. So, even for an expert, it can be difficult to assess whether a rate increase is actually justified. In some cases, however, the staff employed by the Insurance Commissioner do not have the experience or expertise to verify the insurers’ calculations. Since the Commissioner cannot even ask intelligent questions about the applications for approval, they tend to get waived through. This can produce political problems for the state government. For example, in 2010 New Mexico allowed a rate hike for Blue Cross Blue Shield policyholders. When the shouting stopped, the government had approved funding for an independent actuarial firm to vet all rate increases.

It’s the same when it comes to helping policyholders when they run into problems during the claims process. It’s often the case that, if the insurer plays hardball, the consumer’s only choice is to hire an attorney to take over and, if necessary, sue the insurer. This is always difficult for the Insurance Commissioner. The more staff employed to arbitrate between policyholder and insurer, the more expensive the service to the taxpayer. Even the last-resort investigations into alleged malpractice by the insurers is slow moving and often inconclusive unless there’s a formal court ruling clarifying the interpretation of policy terms. In other words, it takes a well-funded and strongly motivated Insurance Commissioner backed by a team with relevant expertise to stand up to the local insurance companies. With individual health insurance becoming so expensive, this is a worrying situation. Indeed, with there being no sign of any way to hold down the cost of health care services, further health insurance rate increases seem likely. Even an independent expert may be forced to accept rate increases if costs keep rising.

Each state must have a working exchange in place come 2014. Note this is not a requirement simply for a proposal or a detailed specification. The actual exchange must be up and working. That means commissioning the design now, allowing plenty of time for the coders to work their magic and then debug until the exchange actually works. Most experts take the view this is getting close to the deadline for beginning the work if a properly tested exchange is to be ready in time. This is reinforced by the federal government which is providing funding support on a use-it-or-lose-it basis. If states have a viable plan and greenlight the project, they get the money. The latecomers either pay for the work out of their reserves (not a good thing given most states are running a deficit) or they accept the electronic exchange provided by the federal government.

As an example of how some states are approaching the problem, let’s look at Illinois. Lawmakers are now considering a bill to approve work on the exchange and, equally important, to create the management structure to oversee the operation of the exchange once it’s up and running. The bill calls for the initial work to be complete by June 2012 which is the deadline for access to federal funding — estimated to be about $150 million for the hardware and software. Because of pressure on the state budget, the unanswered question for now is who will be responsible for paying the administrative costs of the exchange after 2014. Independent experts estimate this will be about $75 million per year. As the Affordable Care Act is written, it appears this must be paid by the state but it’s possible new regulations could change this.

While we wait for all this to become more clear, the latest estimates for the cost of insurance through the exchange are encouraging. Taking current reality, some 1.7 million are uninsured and a floating population of 1.4 million is expected to use the exchange. Assuming about 1 million become steady users within the first two years, the health insurance plan would cost about $12 per month. If the poor were to be charged extra to cover the administrative costs, this could make the insurance significantly less attractive. This will genuinely be cheap health insurance for the poor of Illinois and a good model for all to follow.

Let’s take the issues of contraception, sterilization and abortion. All three are a sin according to the Catholic Church yet, if a Catholic employer is mandated to offer a health plan to its employees, any insurance including these services would be immoral. According to the Church, you cannot be a good Catholic and offer your employees contraception and sterilization, let alone abortion. In fact, the Catholic employers would be paying for these services. Given the number of schools, hospitals and charitable organization run directly by the Catholic Church, this would be money paid out by the Church itself. But here’s the problem. Not everyone employed by a Catholic organization is a Catholic. In any event, many would argue that it’s for the woman to choose whether she wants access to services affecting her reproductive health, including abortion. It should not be for one group to impose its morality on another. If everyone is free to hold whatever beliefs they wish, it would be wrong of any employer to penalize one group of employees whose conscience permits them to access treatment considered necessary by their doctors.

We then get into a very difficult area. Suppose the employer is a Moslem and believes that the use of all stimulants is immoral. Should that employer be allowed to argue an exemption for the treatment of alcohol or drug addiction. The same might occur if the employer considered homosexuality sinful and so wished to deny treatment if an HIV infection developed. In states which allow termination at will, the employer could theoretically end the employment of anyone disapproved (subject to the laws of discrimination). That the same employer might be obliged to pay for health insurance cover promoting an immoral lifestyle or paying for treatment for the results of an immoral lifestyle is considered offensive by many.

What we believe can make it difficult for us to walk through life without upsetting others. So here’s the question. Neither religious belief nor abstract ideas of morality have the force of law. If we can opt in and out of obeying the law just because we happen to be a member of a group with a particular set of beliefs, this is a recipe for chaos. What treatment is sought under a group health insurance plan should be a matter of conscience for each individual.

In the last paragraph Issue 3 was described as a gesture. It wants to use the ballot box to prevent Ohio from going down the same road as Massachusetts. Although quite what’s wrong with the health care mandate in Massachusetts is not clear. It should be said the resulting level of health care provision is very popular with those who actually live there. However, the Ohioan supporters of Issue 3 are taking a strictly libertarian approach. They want to assert their rights as citizens to ignore the law of the land. And that’s where all the problems really start.

Our great country is one nation made up of sovereign states. Except the sovereignty is not absolute. In many areas of our lives, federal law prevails. The test, of course, is whether each federal law is constitutional. That’s where the Supreme Court comes in. Should it decide the Affordable Care Act is unconstitutional by imposing a mandate, no state in the union will be obliged to apply it. But if the Supreme Court decides this Act is a proper use of the law to regulate interstate commerce, every state will be obliged to apply it. That states have some degree of sovereignty does not give states freedom to decide which laws they will or will not apply. It’s all or nothing in this system.

So no matter what happens in the ballot, Ohio will not be free to do as it wishes but, as a piece of political theater, it could have quite important implications. This will be the first time the people have been given a formal chance to express an opinion on the merits of the Affordable Care Act. It will carry far more weight than surveys. Should the vote be against the mandate, it will be used by the GOP to argue all reform of health insurance should be stopped. Should this view prevail, there can be no more cheap health insurance. The premium rates will only fall if everyone is obliged to buy a plan.

As you may have noticed, the Republican party is currently deciding who should run for President. The two candidates currently disputing the lead are Mitt Romney who’s the Governor of Massachusetts, and Rick Perry who’s Governor of Texas. By one of those quirks of fate, these two men also represent a polarized view of health care. Mitt Romney signed a law creating a mandate in Massachusetts, while Rick Perry is as completely anti-scrounger as it’s possible to get — those who can’t stand on their own feet will be left to die where they lie.

The Gallup survey of 177,000 adults over the first six months of this year shows an average of 16.8% of adults have no insurance, i.e. about 52.5 million people are uninsured. If we count “uninsured” as meaning the individual has no private insurance nor access to Medicare, Medicaid or Veterans Affairs cover, Massachusetts has the best record in the US with only 5.3% of its citizens without cover. It’s interesting that, in the five years since the mandate came into law, it has still to produce universal cover. Perhaps the mandate will never enable everyone to find cover. This contrasts with Texas which, at 27.2%, has the worst record in the US. This also highlights another interesting phenomenon. The largely Democratic north-east has the lowest numbers of uninsured, whereas the Republican south tends to have the highest rates. This represents something of a shift in the politics of health care.

Back in 2001, Rick Perry was talking up the possibility of Texas funding health care for both US and Mexican border residents. The Texas lawmakers formally investigated the option of bi-national health cover. Although the proposal was later abandoned, Perry was in favor of some form of socialized medicine. This does rather force the moral question. As a leader of people, does a governor not have a duty to promote the well-being of all the people? As a Christian, should we not expect Rick Perry to have more compassion? This is not arguing that all states should promote cheap health insurance for all its adult citizens. But it is suggesting we should be doing more for the 52 million Americans who are currently uninsured. If the Republican party wants to repeal Obamacare, it should be honest in making proposals for how to repair the broken health insurance service.

In the midst of all this, you have the problem of health care. Takes states like Kentucky, North Carolina and Tennessee where up to 40% of the population live in rural communities. With due respect given to these states, there’s real poverty in many of these areas and, as a result, higher levels of chronic disease among people less likely to carry current insurance. This places a heavy burden on Medicare and Medicaid at a time when the tax revenue collected by both the federal and state governments is falling. This loss in revenue comes against a background of consistently rising costs. It’s not just the rise in the retail prices for prescription drugs. With few doctors prepared to provide care to dispersed rural communities, financial incentives have been offered. The for-profit clinics and hospitals are struggling because of the high number of uninsured and so charge higher rates.

This is the time for local communities to encourage the creation of more non-profit hospitals offering benefit plans to their local communities. In policy terms, this requires local government to map where everyone lives and what their needs are both now and in the future. Only then can there be proper planning. One of the key issues is going to be changing attitudes and lifestyles. With fewer resources, there must be greater emphasis on preventative medicine. There are major benefits if more people can be persuaded to eat a healthy diet, exercise more, drink less and quit smoking. Only when people help themselves and are routinely screened for the more common illnesses, can we make the most effective use of the scarce resources. This is being backed up by the larger employers who are struggling with the rising premium rates as we only slowly pull out of the recession.

More employers are now working with local government to establish their own health insurance plans. In some cases, this means setting up clinics inside large industrial or commercial buildings. Employing medical staff directly represents a big saving. If this waits for Washington to move, these states will be waiting indefinitely. It’s all going to come down to self-help on a limited budget. Obamacare is, of course, going to produce a crisis as more people gain access to individual health insurance plans. This commitment could not have come at a worse economic time for the poorer rural states. If the best decisions are going to be taken, all the stakeholders must come together to discuss how to make the best use of the scarce resources. Hopefully, the can-do spirit will get things done.