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 It's just a matter of months now before President Obama and the Democrat Party announce their Health Care reform  bill. There is still much debate on Capitol Hill as to what the best course is to reform the U.S. Health Care system.  Both  parties (and most American's) feel that something has to be done. The question is, what is the best course of  action?  There are those who believe that a "Single Payer" system would be the best option. The President does not  agree.  Although he clearly stated his support for such a system during his campaign. Now, he is promoting a  "Public  Option"  which by all estimates will cost the U.S. Tax Payers between $2 and $3 Trillion Dollars over the next decade.

 Since there are so many ideas on the table, it is difficult to know what the right course of action is. Most especially  when you are on the outside looking in. Recently ABC's 20/20 program did an in depth study of this issue. The result of  which clearly outlined the problems with the U.S. Health Care System and what needs to be done on a National scale  in  order to truly reform our Health Care System. If you have not seen the 20/20 episode entitled "Sick in America"  with  John Stossel. Please take the time to watch all 6 videos. It will take about 45 minutes of your time but it is well  worth  it to know what's really going on and what can be done right now to truly reform the U.S. Health Care system.  Most  importantly it can all be done without spending Trillions of U.S. Tax Payer Dollars. In fact, it will SAVE us money!

Sick in America" (Part 1 of 6)

"Sick in America" (Part 2 of 6)

"Sick in America" (Part 3 of 6)

"Sick in America" (Part 4 of 6)

"Sick in America" (Part 5 of 6)

"Sick in America" (Part 6 of 6)

A common example used to further the cause of adopting a Single Payer system in the United States is to point out how well it is working in countries such as France and Canada. 20/20 touches on this in the above episode. However, very few have done a more in depth study of Canada's Single Payer system than documentary film maker Stuart Browning. For even more about what is really going on with the Canadian  health care system please watch his short but very informative documentary videos below. Again, well worth your time.

 

 

Medical care in the United States is derided as miserable compared to health care systems in the rest of the developed world.  Economists, government officials, insurers and academics alike are beating the drum for a far larger government role in health care.  Much of the public assumes their arguments are sound because the calls for change are so ubiquitous and the topic so complex.  However, before turning to government as the solution, some unheralded facts about America's health care system should be considered, says Scott W. Atlas, a senior fellow at the Hoover Institution and a professor at the Stanford University Medical Center. 

Americans have better survival rates than Europeans for common cancers:

• Breast cancer mortality is 52 percent higher in Germany than in the United States, and 88 percent higher in the United Kingdom.
• Prostate cancer mortality is 604 percent higher in the United Kingdom and 457 percent higher in Norway.
• The mortality rate for colorectal cancer among British men and women is about 40 percent higher.

Americans have better access to treatment for chronic diseases than patients in other developed countries:

• Some 56 percent of Americans who could benefit are taking statins, which reduce cholesterol and protect against heart disease.
• By comparison, of those patients who could benefit from these drugs, only 36 percent of the Dutch, 29 percent of the Swiss, 26 percent of Germans, 23 percent of Britons and 17 percent of Italians receive them.

Lower income Americans are in better health than comparable Canadians:

• Twice as many American seniors with below-median incomes self-report "excellent" health compared to Canadian seniors (11.7 percent versus 5.8 percent).
• Conversely, white Canadian young adults with below-median incomes are 20 percent more likely than lower income Americans to describe their health as "fair or poor."

Americans spend less time waiting for care than patients in Canada and the United Kingdom:

• Canadian and British patients wait about twice as long -- sometimes more than a year -- to see a specialist, to have elective surgery like hip replacements or to get radiation treatment for cancer.
• All told, 827,429 people are waiting for some type of procedure in Canada.
• In England, nearly 1.8 million people are waiting for a hospital admission or outpatient treatment.

Source: Scott W. Atlas, "10 Surprising Facts About American Health Care," National Center for Policy Analysis, Brief Analysis No. 649, 3/24/09 http://www.ncpa.org/sub/dpd/index.php?Article_ID=17770

 
Because of how the Single Payer System is designed, citizens of England & Canada have NO WHERE NEAR the choices that we as American citizens do. As a matter of fact, until very recently (2005) it was simply not possible for a Canadian citizen to pay for their own health care or to purchase private medical insurance that would "bump them up the long waiting list" for medical treatments. The reason Canadian citizens now have the right to do so (and it is still limited) is a direct result of long hard battles (many that are still being fought) that have been waged by brave Canadian citizens like Dr. Jacques Chaoulli who took his clients case all the way to the Canadian supreme court and won! Dr. Chaoulli (http://www.healthcoalition.ca/chaoulli.html) and his patient, George Zeliotis, launched their legal challenge to the Canadian government's monopolized healthcare system after waiting more than a year for hip-replacement surgery.
 
Canada's high court found for the plaintiffs and in doing so issued the following statement: "The evidence in this case shows that delays in the public healthcare system are widespread, and that, in some serious cases, patients die as a result of waiting lists for public healthcare. The evidence also demonstrates that the prohibition against private health insurance and its consequence of denying people vital healthcare result in physical and psychological suffering that meets a threshold test of seriousness." Furthermore, Justice Marie Deschamps said, "Many patients on non-urgent waiting lists are in pain and cannot fully enjoy any real quality of life. The right to life and to personal inviolability is therefore affected by the waiting times."

Furthermore, the Vancouver, British Columbia-based Fraser Institute which keeps track of Canadian waiting times for various medical procedures. According to the Fraser Institute's 14th annual edition of "Waiting Your Turn: Hospital Waiting Lists in Canada (2006)," total waiting time between referral from a general practitioner and treatment, averaged across all 12 specialties and 10 provinces surveyed, rose from 17.7 weeks in 2003 to 17.9 weeks in 2006. Depending on which Canadian province you live in, a simple MRI requires a wait between 7 and 33 weeks! Orthopedic surgery could require a wait of 14 weeks for a referral from a general practitioner to the specialist and then another 24 weeks from the specialist to treatment! For even more real life horror stories about Canadian citizens left in the lurch by the Canadian healthcare system read the well researched and fact based Wall Street Journal article entitled "Too Old For Hip Surgery" here: http://online.wsj.com/article/SB123413701032661445.html?mod=article-outset-box This is what happens when you put government in control of your health care decisions. Doing so in this country, would be nothing short of a train wreck. Anyone who thinks otherwise is simply uninformed or "willfully ignorant".

What has our government done, to convince people to hand over our very health freedoms for it to govern over?
Katrina……..?
Fannie Mae – bailout? (this is a government entity who's employee's receive bonuses!) What other government employee receives bonuses for doing their jobs?
Social security – bankrupt ? (robbed for other expenditures)
Medicaid – ? (robbed for other expenditures)
$2 trillion Porkulus bill - ? (and growing)
AIG – bail out, yet nobody knows where's the money gone? No committee of oversight in place (was promised by our representatives to be in place immediately)
Gas prices - ? (50% of every dollar at the pump goes to Washington) But who did you point your finger at as the problem?

Since our government "cannot" be sued, how will one be able to be recompensed for its malfeasance or neglect? How will the government, once it tells 300 million people "go see the doctor we will pay all the bills", be able to control the consequences? By overwhelming our medical profession or breaking it, will come another "grand government solution," we need more money to fix it"! You are already familiar and have accepted this excuse for too long, and know this to be their power solution. Our government has impoverished our families' financial freedom to pay our own way, by immoral taxation. Want to know what such a government endeavor will cost the U.S. Tax Payer? Read the April 12, 2009 Wall Street Journal article entitled "The End of Private Health Insurance" http://online.wsj.com/article/SB123958544583612437.html?mod=googlenews_wsj

Real healthcare reform can be accomplished through consumer education, weeding out abuse of existing Federal entitlement programs (via a legitimate needs assessment) and continued funding of State sponsored Risk Pools so that people who are declined for insurance have an affordable option to continue coverage if declined on the individual major medical market. Following these few simple steps will go a long way towards not only maintaining our current health care system, but also towards keeping the bulk of our nations risk where it belongs, namely with the private health insurance industry. In light of the recent multi Trillion Dollar "Bail Outs" and many other failing corporations coming to the table with their hats in their hands (and their private jets on the tarmac) the last thing our government should do is start cutting more blind "bail out" checks in an effort to "reform" the U.S. health care system.

Even more suggestions towards reforming the US Healthcare system were made by United Healthcare CEO, Stephen J. Hemsley. Read his suggestions made on 4/9/09  http://www.insurancebroadcasting.com/insurance-news-042009-3.htm

Find out what's really driving the increase in Health Insurance premiums. Read the in depth study by the Institute of Health Care Knowledge published May 2009:  http://www.wellpoint.com/pdf/Premium%20Cost%20Drivers.pdf

Is Health Care A Fundamental Right? If So What Should Governments Role Be?

Washington again at his Farewell Address, September 19, 1796. Regarding using others blood sweat and tears to pay for those who have not earned: What did Jefferson say? “ To take from one, because it is thought that his own industry and that of his fathers has acquired too much in order to spare to others, who, or whose fathers have NOT exercised equal industry and skill, is to violate arbitrarily the first principle of association, the guarantee to every one of a free exercise of his industry, and the fruits acquired by it.”

How does this apply today?

46% of American’s pay absolutely no INCOME taxes! That means the rest of us have the privilege of paying for all entitlements (which are ever expanding). Most recent case in point:

Last year, SCHIP covered about 7 million low-income children and Medicaid covered an additional 23 million. This year, 2009, the U.S House of Representatives passed the H.R.2 SCHIP Expansion Bill which adds another 6.5 million children to Medicaid. In fact, according to U.S. Census Bureau data, 42 million children will now be eligible. The bill also allows States to receive federal reimbursement for adding more immigrant children and pregnant immigrant mothers, and removes the 5 year waiting period now required for legal immigrants to be eligible. This would enable immigrants to become eligible for health benefits the moment they get here!

Currently, the present income eligibility cap is $44,000 for a family of 4. The new bill raised the Medicaid limit to $66,000. New York will even include families who earn $88,000 and other states allow families to subtract from their income calculation what they spend on rent or mortgage or heating or food or transportation. This means that children in some families who have incomes well over $100,000 will now be eligible. With the median U.S. household income around $50,000, 60% of U.S. households still earning less than $62,000. This means that 3 out of 5 American households will now qualify for free health care for their children. It also means that the other 2 out of 5 households will have the burden of paying for all of this!

Back to our forefathers: Jefferson’s Letter to Joseph Milligan, April 6, 1816: ” There lies the distinction of “charity” or coercion. Here stands Jefferson who feared that if citizens became lazy, apathetic, and IRRESPONSIBLE, government would gain ground and become tyrannical and corrupt, plundering taxpayers for special interests and violating even property rights and other freedoms.”

How does this apply today?

With the help of the U.S. Census Bureau, let’s break down the real empirical data behind the “50 million uninsured” in America. Who exactly are they? FACTS:

•  17 Million live in households earning more than $50,000 (38% of American uninsured)

•  9 Million live in households earning more than $75,000 (20% of American uninsured)

•  18 Million of the “young invincibles” (ages 18-34) who spend more money on “cigarettes, entertainment & cell  phone bills. (40% of uninsured)

•  14 Million are eligible for Medicaid and SCHIP due to low income and do not enroll. (31% of uninsured)
      Watch “Uninsured in America”: http://www.youtube.com/watch?v=uKCWbq18bNk&feature=channel_page

•  There are also 12 Million illegal aliens (and growing) who don't buy Health Insurance but still get "free" health care.
  
  So how many are legitimately uninsured? About 8 Million. That's just 18% of the 45 Millions we constantly here about.

Back to our Forefathers: Jefferson again: “We must not let our rulers load us with perpetual debt ($3 Trillion Dollar “Porkulus Maximus” Bill) We must make our election between economy and liberty, or Profusion and servitude. If we run into such debts, as that we must be taxed in our meat and in our drink, in our necessaries and our comforts, in our labors and our amusements, for our callings and our creeds, as the people of England are, our people, like them, must come to labor sixteen hours in the twenty-four, give the earnings of fifteen of these to the government for their debts and daily expenses; and the sixteenth being insufficient to afford us bread, we must live, as they now do, on OATMEAL and potatoes; have no time to think, no means of calling the mismanagers to account; (government) but be glad to obtain subsistence by hiring ourselves to rivet their CHAINS on the necks of our fellow-sufferers…private fortunes are destroyed by public (government) as well private extravagance. Till the bulk of the society is reduced to be mere automations of misery……than begins, indeed, the bellum omnium in omnia (War of all against all) …..and the fore horse of this frightful team is public debt. Taxation follows that, and in its train wretchedness and oppression.” (Letter to Samuel Kerchival, July 12, 1816)

How does this apply today?

Where is the outrage that our children already, BEFORE BEING BORN are now in debt to the government by $35,000 ! Nice immoral profit I say by our government and we haven’t even begun down the slippery slope to “Universal Health Care.” Even before we begin, the $3 Trillion “Porkulus Maximus”Bail Out continues to grow as more and more corporations come to the capital with their hat in their hands and their private jets on the tarmac.

Back to our Forefathers: Jefferson again: “To compel a man to subsidize with his taxes the propagation of ideas which he DISBELIEVES and abhors is sinful and tyrannical.” – Thomas Jefferson

John Adams (Vice President US for 2 terms 1788-1796, and in 1796 became our Second President) On taxation : “Property is surely a right of mankind as real as liberty. Perhaps, at first, prejudice, habit, shame or fear, principle or religion would restrain the poor from attacking the rich, and the idle from usurping on the industrious; but the time would not be long before courage and enterprise (political opportunists) would come and pretexts be invented (socialist agenda) by degrees to countenance the majority in dividing all the property among them, or at least in sharing it equally with its present possessors. Debts would be abolished first; taxes laid HEAVY on the rich, and not at all on the others; (46% of American’s pay NO income tax) and at last a downright equal division of everything be demanded, and voted. What would be the consequence of this? The idle, the vicious, the intemperate would rush into the utmost extravagance of debauchery, sell and spend all their share, and than demand a NEW division of those who PURCHASED from them.’

Thomas Pain (1737–1809) “If, from the more wretched parts of the old world, we look at those which are in an advanced stage of improvement, we still find the greedy hand of government thrusting itself into every corner and crevice of industry, and grasping the spoil of the multitude. Invention is continually exercised, to furnish new pretenses for revenues and taxation. It watches prosperity as its prey and permits none to escape without tribute.”

Daniel Webster (1782-1852) “An unlimited power to tax involves, necessarily, the power to DESTROY.”

How do these comments apply today?

If taxation strengthens a government, while relieving it’s citizens of the freedoms above forewarned from our Forefathers, how can anyone believe taxing Americans at 60% or more (to fund a "public option") is the solution? What else could stifle personal drive and achievement more than even more taxation?

Regarding a “Public Option.” There are several reasons why a Public Option will not work. Firstly, the private sector can not compete with a Public Option. So the lie that it will just create “healthy competition” is just that. An INSIDIOUS Lie perpetrated by a Government with an unholy lust for even more power. Why is it a lie?

Because unlike the Federal Government who can tap in to the U.S. Treasury (as they have been doing feverishly lately) when claims surpass revenue. The private sector is held to a higher standard. Namely, fiscal responsibility. If claims supercede revenue, an insurance company must be held to the ramifications that happen to any company that does not balance it’s portfolio correctly. Namely, FAILURE (except, of course if that company is AIG who gets bailed out over AND OVER again by our precious BLOOD SWEAT and TEARS)!

SIDE BAR: Quick Translation of the term “Blood Sweat & Tears” for the aforementioned 46%. “Blood Sweat & Tears” means income taxes.

SIDE BAR: Further clarification of the term “income tax”. This is a percentage of income that is forcibly taken from roughly half of the American population when they produce an income.

Once the insurance companies fail (shortly after the “Public Option” starts promoting “Healthy Competition”) we will be left with “Medicare” for all! But wait! How’s Medicaid & Medicare working now? Let’s see. At the current rate of Medicare expenditures, by the time I am 65 there will be no Medicare for me according to ALL economist (on both sides of the isle). Why? Because they have been robbed for other expenditures by a fiscally irresponsible, over burdensome Federal Government. Who’s answer to EVERYTHING is to throw money at it! Easy to throw when it’s not yours.

The private sector does not have the luxury to play with America’s BLOOD SWEAT & TEARS. We must balance our portfolios responsibly and consistently or we will not have the the funds to pay the big claims when they arise (and they do arise, and they do so often). This being the case, it comes down to who the American Tax Payers (again, I stress the 50% that actually pay income taxes) want to handle their medical care. And overwhelming, those tax payers want choice and fiscal responsibility. They will receive neither through a government run “Public Option.”

Ok, well then we’ll just lean on Medicaid. Really? Will that be before or after the recent Medicaid Expansion of $87 Billion is used up or after the 78.2 MILLION Baby Boomers suck it dry to care for their long term care expenses? More reasons why a “Public Option” will not work? Read: http://www.heritage.org/Research/HealthCare/bg2267.cfm

Even though neither a Single Payer nor a Public option will work. We still definitely need health care reform on many levels and if Government must play a part there are intelligent things they can do. Here’s where they can actually help:

•  Weed out all of the illegals who are sucking our Medicaid system dry such as in Illinois. Good old “Blago” enrolled thousands of Illegals in to our Medicaid system, thereby running the program in the ground & leaving our Illinois Medicaid system approx. $1.5 BILLION behind in payment of claims to physicians who have been providing “free” care to all illegals who were lucky enough to flock to the State of Illinois to insure themselves for “free”. By the way, this is the reason he was impeached so quickly. The Illinois Senate didn’t need the Federal Wire Taps.
   

•  Instead of bailing out GM with Billions of our blood sweat and tears and then letting them file bankruptcy 3 months later. Why not fund a NATIONAL High Risk Pool for those who are rendered uninsurable? We already have such State run High Risk Health Insurance pools in the majority of States. These Risk Pools will cover anyone regardless of their medical history. The problem is they are under funded so the premiums are extremely high. Instead of spending $1.6 Trillion to insure only 11 Million of the 45 Million uninsured. LEAVE the bulk of the nation's risk where the money is, namely with the insurance companies. Then provide a National Federal & State funded Risk Pool for those who are rendered uninsurable. Since the uninsured far outweigh the uninsurable, this would cost far less than the currently proposed $1.6 Trillion over the next 10 years.
   

•  Pass a law that mandates that all American’s, who can afford to purchase Health Insurance (remember the 35 Million) actually do so! Pass a law that states that they must purchase some basic level of Health Insurance coverage for themselves and their dependents. The Fed has has already helped design Consumer Driven Tax Qualified Health Insurance so the premiums remain affordable and the family has an impetus to help control costs. In fact, no other form of Health Insurance lowers your risk each year. People need to know about these new Consumer Driven Health Insurance options. Why would passing a Health Insurance Mandate work? Remember car insurance? It used to be that you could drive around like a moron without it. Congress then mandated (and rightfully so) that ALL drivers purchase some basic level of Car Insurance to protect themselves and those who they may injure. This worked for the car insurance industry and it would do the EXACT same thing for the Health Insurance industry. Adding to the national risk pool 35 Million more American’s would drive down Health Insurance premiums for all American’s. It’s just an actuarial fact.
   

•  Establish a Federal oversight committee to regulate and hold accountable physicians who make medical mistakes. What’s one of the biggest reasons why health care is so expensive? Hint: It’s not “rich CEO’s” and “outdated medical records transfer processes.” It’s Medical Mistakes! Here’s the real facts you won’t find in the media outlets:

1994: Five years after a groundbreaking Institute of Medicine report focused attention on medical errors in hospitals, Americans say that they do not believe that the nation’s quality of care has improved. In fact, 1 out of 3 patients states that they have experienced a serious medical error http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.534

1995: A Study published in the Journal of American Medical Association (JAMA) found that only two percent of medication errors that occurred during the medication administration process were intercepted.
a. More people die from medication errors than from work place injuries
b. Medication errors account for approximately one out of 131 outpatient deaths and one out of 854 inpatient deaths.

1999: Institute of Medicine (IOM) releases its first report on healthcare quality and medical errors. http://www.iom.edu/?id=12735 The Study finds in part that:

    a. Medical errors are responsible for injury in as many as 1 out of every 25 hospital patients.
    b. Between 44,000 and 98,000 Americans die each year from preventable medical errors in hospitals alone.
    c. The deaths from preventable medical mistakes are equivalent to the number of people who would die if a jumbo     jet crashed EACH AND EVERY DAY OF THE YEAR, and all its passengers died!
    d. Medical errors cause more deaths than motor vehicle accidents, breast cancer or AIDS…..and this study is TEN     YEARS OLD and STILL no Federal oversight committee! Oh wait! It gets worse!

2002: A Study issued by the United States Pharmacopeia (USP) concluded that more than 200,000 medication errors occurred during 2002

2004: CDC reports that 90,000 patient deaths occur each year due to patients contracting hospital acquired infections.  http://www.cdc.gov/ncidod/dhqp/pdf/nnis/2004NNISreport.pdf
    a. Many hospital acquired infections are caused by health care workers who fail to wash their hands in between patients.

2006: Studies assessing the state of hospital patient safety conclude that current progress is slow, results in general are at best modest, and the gap between the best possible care and actual care remains large.  http://www.healthgrades.com/media/dms/pdf/PatientSafetyInAmericanHospitalsStudy2006.pdf

More Facts:

Preventable medical errors result in extended hospital stays, expensive treatment for chronic medical conditions and astronomical medical costs that are associated with treating debilitating life-long illnesses. Some experts state that these costs may be in the range of $150-200 Billion dollars per year. Gee, where else could we spend that money??? Quick reminder:

ALL of the aforementioned happened under the nose of our Federal Government. And we want them to regulate Health Care?? Let’s not save ALL of our anger for the “greedy” insurance companies and “over paid” doctors and CEO’s. Let’s focus our Anger on our GOVERNMENT who has allowed this systemic problem to continue over three administrations!

Ask yourself, why does the health care industry basically regulate and report on itself? Why is certification and accreditation voluntary? Why don’t we have a Federal agency that acts like the FAA and investigate medical mistakes, just like airline accidents or near misses? Why do only some states have mandatory reporting requirements of medical errors? All Good Questions that need to be answered before we hand over our very health freedoms to the Government to “regulate”.

By the way, ever wonder why those 35 Million don’t purchase Health Insurance? Because it’s FREE!!! There are hundreds of Free Hospitals & Clinics around the country: http://www.healthcentral.com/diabetes/c/17/66884/affordable-medical
Add to that the “compassionate care” that any one can get at every Emergency Room in the U.S. and is there any wonder why so many chose not to insure themselves? But that’s the point here. NOTHING is “free”! It’s all on the backs of the 54% of American’s who actually pay income taxes and this already MASSIVE burden will increase exponentially once Health Care is “FREE” for everyone!

Does this mean then that we should stop providing for those who are truly in need? Of course not. In fact, providing for those who are truly in need is one of the things that makes America great. We not only provide for those in our own country but we spill our precious blood on foreign soil around the globe defending the rights of our allies and protecting Liberty. We will continue to do so. My point is that what used to be entitlements for those who legitimately need them has now become entitlements for those who can MOST CERTAINLY provide for themselves.

What our forefathers envisioned was a “Just Society”. A Society that grows great upon the efforts of each citizens efforts and yet remembers that there are those amongst us WHO CAN NOT (due to infirmity, age, mental disability, disenfranchisement etc.) And we have always provided for those who are truly in need. And we will continue to do so.

Fiscal Conservatives believe wholeheartedly in helping those that are truly in need. But those that are not truly in need should PROVIDE FOR THEMSELVES! The decision to help those truly in need should be made by the hearts and minds of the individual citizen, not funded through increased tax dollars by an ever encroaching government.

Bill & Melinda Gates have contributed Billions of dollars to humanitarian efforts inside and out of this country. Oprah Winfrey has done the same, to name just a few. But no one told them they HAD to. No one forcibly took that money (other than the Millions in taxes they already forfeit to the government). Instead, their hearts were motivated to do so and this is the crux of the matter. Free citizens do not need their Government to tell them how to spend their money. Free citizens do not need their Government encroaching on their very lively hoods. And MOST IMPORTANTLY Free Citizens can certainly spend their money better than the Federal Government. Why? Because they have a vested interest in where that money goes due to the fact that they have EARNED it!

Medicaid Expansion Buckles Under The Stress of "Open Enrollment"

I have been an insurance broker in the state of Illinois for the past 15 years and I have seen first hand what happens when an over burdened, tax funded, Government controlled, entitlement program like Medicaid is offered to those with incomes well into the middle class.

Last year, SCHIP covered about 7 million low-income children and Medicaid covered an additional 23 million. This year, 2009, the U.S House of Representatives passed the H.R.2 SCHIP Expansion Bill which adds another 6.5 million children to Medicaid.

In fact, according to U.S. Census Bureau data, 42 million children will now be eligible. The bill also allows States to receive federal reimbursement for adding more immigrant children and pregnant immigrant mothers, and removes the 5 year waiting period now required for legal immigrants to be eligible. This would enable immigrants to become eligible for health benefits the moment they get here.

Currently, the present income eligibility cap is $44,000 for a family of 4. The new bill raised the Medicaid limit to $66,000. New York will even include families who earn $88,000 and other states allow families to subtract from their income calculation what they spend on rent or mortgage or heating or food or transportation. This means that  children in some families who have incomes well over $100,000 will now be eligible.

With the median U.S. household income around $50,000, 60% of U.S. households still earning less than $62,000.  This means that 3 out of 5 American households will now qualify for free health care for their children. It also means that the other 2 out of 5 household will have the burden of paying for all of this!

Let's take a look to see how some of these programs are doing. Click here to read about the Medicaid "expansion" program enacted in my home State, Illinois, by our recently impeached and now infamous Democratic Governor Rod Blagojevich.

In fact, Blago was so "generous" that he expanded these Medicaid entitlement programs to include a defunct "All Kids Covered" plan, a defunct "Mom's & Babies" plan and an equally defunct "Family Care" plan.

These entitlement programs were designed to provide FREE health insurance coverage to all low income women who are currently pregnant (Mom's & Babies) and all children - here legally or ILLEGALLY (All Kids Covered) but they were also to provide FREE health insurance to all low income mothers of children who are insured under the "All Kids Covered" program (Family Care).

Now, one does not need to study actuarial science to quickly conclude that these types of entitlement expansion programs simply can not continue to work without massive and endless influxes of tax payer dollars. In fact, the State of Illinois is currently $1.5 Billion (yes, that's BILLION) behind in payment of claims to medical practitioners who have already provided treatment to program recipients. Furthermore, submitted claims by unpaid practitioners have accrued a potential liability of $81 million in interest due to payment delays over the past 8 years. Read more about the problems with claims payments here. 

Update: As of January 2009 a moratorium has been placed on the sliding scale portion of the Illinois Family Care and the Mom's & Babies program. One can only wonder why. Could it be due to lack of funding?

Illinois had been lauded as the "Flagship" state for all others to follow regarding the expansion of the Medicaid entitlement programs. If this is the template for all others to follow, then god help us all, or at least those of us that actually fund the Medicaid system through our hard earned tax dollars.

Weighty decisions such as expanding the Medicaid system to virtually "All Kids" regardless of their actual need, simply can not be made based entirely on emotion! Prudent decision makers must weigh the desire to help all mankind against fiscal REALITY. There simply is not enough money to provide such irresponsible expansions of the Medicaid program.

This is the real reason why President Bush vetoed the SCHIP program after the $780,000,000,000 (BILLION) "Porkulus Maximus" Bailout Bill passed in the Senate which was pushed hard by the Democratic Party. Of course, despite the caution of conservatives in the Republican party, the SCHIP bill did pass both the House and
Senate in 2009.

But how can we afford to pay for such entitlement programs? Should we limit these programs to those that truly cannot afford to purchase individual health insurance on the open market? How will we determine who is deserving of such entitlements (e.g. legal residents of this country who actually qualify during a legitimate needs assessment.)

What about personal responsibility? Should we also pay for the middle class if they can afford to purchase health insurance on their own?

Expansion of these entitlement programs to the middle class may be well meaning, but it is undoubtedly a fiscally irresponsible act that will end up crippling the already over burdened system.

We might not feel the direct impact of this now, but we most certainly will when all of the "Baby Boomers" start entering the Assisted Living and Long Term Care arena. Should we just let Boomers who don't have the forethought to purchase Long Term Care insurance off of the financial hook while taxpayers shoulder the burden?  

Today, those of us who are in need of health insurance have many options to choose from and, contrary to popular belief many of these options are priced very affordably.

An integral part of being personally responsible is that you take the time to explore ALL of your options so you can fiscally sound decisions BEFORE leaning on a an already over burdened Medicaid system.

If you have other options, you should never leave any decisions up government bureaucrats, especially your healthcare.

Health Insurance: "The Best Policy Is A Great Agent"

I have been a health insurance broker for 15 years now and every day I read more and more "horror" stories that are posted on the Internet regarding health insurance companies not paying claims, refusing to cover specific illnesses and physicians not getting reimbursed for medical services. Unfortunately, insurance companies are driven by profits, not people (albeit they need people to make profits). If the insurance company can find a legal reason not to pay a claim, chances are they will find it, and you the consumer will suffer.

However, what most people fail to realize is that there are very few "loopholes" in an insurance policy that give the insurance company an unfair advantage over the consumer. In fact, insurance companies go to great lengths to detail the limitations of their coverage by giving the policy holders 10-days (a 10-day free look period) to review their policy. Unfortunately, most people put their insurance cards in their wallet and place their policy in a drawer or filing cabinet during their 10-day free look and it usually isn't until they receive a "denial" letter from the insurance company that they take their policy out to really read through it. The majority of people, who buy their own health insurance, rely heavily on the insurance agent selling the policy to explain the plan's coverage and benefits. This being the case, many individuals who purchase their own health insurance plan can tell you very little about their plan, other than, what they pay in premiums and how much they have to pay to satisfy their deductible. 

Excellent Health Insurance Advice from Doctor Jennifer Ashton on the CBS Morning Show 4/9/09

For many consumers, purchasing a health insurance policy on their own can be an enormous undertaking. Purchasing a health insurance policy is not like buying a car, in that, the buyer knows that the engine and transmission are standard, and that power windows are optional. A health insurance plan is much more ambiguous, and it is often very difficult for the consumer to determine what type of coverage is standard and what other benefits are optional. In my opinion, this is the primary reason that most policy holders don't realize that they do not have coverage for a specific medical treatment until they receive a large bill from the hospital stating that "benefits were denied." Sure, we all complain about insurance companies, but we do know that they serve a "necessary evil."

There are so many variables that consumers have to be aware of when it comes to buying health insurance. These variables, and confusing insurance terminology, are often difficult for the average consumer to understand which is why many small business owners actually put off looking for a new health plan until their rates have skyrocketed to the point that they can no longer afford the monthly premiums. Business owners, who find themselves in this position, often place a greater emphasis on how much the new plan will cost, rather than placing an emphasis on what benefits the new plan will actually offer. 

Quite often, consumers that base their purchasing decision entirely on price, don't even realize that their new plan may not provide coverage for specific medical conditions or that the amount allotted for certain treatments may be extremely limited. And, it usually isn't until they receive a large bill from a medical provider which states that "claims were denied" that they realize that they made a critical mistake in plan selection.

As a small business owner, myself, who primarily deals with other small business owners, I have come to the realization that part of the problem is that it is extremely difficult for individuals purchasing their health plan on the open market to distinguish the difference among health plans. It is also equally difficult for consumers to determine what type of health insurance coverage they actually need for their particular situation. 

Remember, there is a big difference between the type of health plan consumers actually "need" and the type of health plan consumers actually "want." Let me explain. 

Recently, I have read many blog articles that seem to stress that consumers should purchase health plans that offer 100% coverage with a very low deductible. 100% coverage means that after the deductible is met, usually $250, the plan will pay 100% of all covered medical expenses. 

Although I agree that these types of health plans have a great "curb appeal." I can tell you from personal experience that these plans are not for everyone, nor are they affordable. 

Will a low deductible plan that offers 100% coverage offer the policy holder greater peace of mind? Probably. But is a low deductible health plan that offers 100% health insurance coverage something that most consumers really need? Probably not. 

In my professional opinion, consumers must achieve a balance between four important variables; wants, needs, risk and cost when they purchase a health plan. Just like the car analogy, it is important for healthcare consumers to understand what type of health insurance benefits are automatically included or standard and which health insurance benefits are optional. For example, on most health plans, maternity and prescription drug coverage is optional. 

With this in mind, if one is healthy, takes no medications and rarely goes to the doctor, do they really need a 100% plan with a $5 co-payment for prescription drugs if it costs them $300 dollars more a month?  

Would it benefit a person to pay $200 more a month to have a 90/10 plan with a $250 deductible, or should they purchase an 80/20 plan with a $2,500 deductible which allows them to save $200 a month? Wouldn't the 80/20 plan still offer you adequate coverage? Isn't it more cost effective to put that extra $200 that would be spent on insurance premiums, totaling $2,400 per year in their bank account, "just in case" they may get sick or injured and might need to pay their $2,000 deductible?

Isn't it smarter to keep your hard-earned money yourself, rather than pay higher monthly premiums to an insurance company for an illness or injury that may never happen?

This is just one example of consumer-driven health care. Another example is an HSA qualified HPHP. A HSA qualified HDHP (Health Savings Account qualified High Deductible Health Plan) may offer a more affordable healthcare option to individuals that are searching for a health plan with very low monthly premiums. Typically, these plans offer policyholders greater flexibility and control in where their health care dollars are spent. Plans often come with a fixed aggregate family deductible, which mean that a separate deductible does not have to be met for each family member on the plan.

In addition to the significant cost savings, policyholders can fund their Health Savings Account (HSA) to pay for routine medical expenses or alternative medical therapies, like acupuncture.  Any money in the HSA that is not used for medical expenses can be rolled over to the next year and excess funds can be transferred to a tax deductible, tax deferred, interest bearing account, commonly referred to as a "Medical IRA." These types of health plans can offer tremendous tax advantages to policyholders. Not only can policyholders save money on their health insurance premiums, but they also can use this savings to build a nest egg for retirement. Many HSA administrators now offer thousands of no load mutual funds to transfer your HSA funds into so you can potentially earn an even higher rate of interest.

For more information on HSA qualified HDHPs, click here.

In my experience, I believe that individuals who purchase their health plan based on "wants" rather than "needs" feel the most defrauded or "ripped-off" by their insurance company and/or insurance agent. 

In fact, I hear almost identical comments from almost every business owner that I speak to about health insurance. 

Comments, such as:

• "I have to run my business; I don't have time to be sick!"

• "I think I have gone to the doctor 2 times in the last 5 years" .......and

• "My insurance company keeps raising my rates and I don't even use my insurance!"

Again, as a small business owner myself, I can understand the frustration that many small business owners express. So, here is the $64,000 question: 

Q. Is there a simple formula that everyone can follow to make health insurance buying easier?

A. YES. Become an INFORMED insurance consumer!

If you are wondering what I mean by this, let me explain: 

Every time I contact a prospective client or call one of my client referrals, I ask that person a list of questions about their current health insurance policy. You know, that policy that is in their dresser drawer or filing cabinet. 

That same policy that they bought to protect themselves and their family from that "worse case scenario" so they wouldn't have to file bankruptcy or lose their home due to unpaid medical debt. 

That policy that they thought promised coverage for that $500,000 life-saving organ transplant, for the 40 chemotherapy treatments that they may have to undergo if they were diagnosed with cancer or the many months of physical and/or speech therapy that they might need to fully recover from a stroke. 

Q. So, what do you think happens almost 100% of the time when I ask these individuals "BASIC" questions about their health insurance policy?

A. They almost always do not know the answers!   

The following is a list of 10 Questions that I routinely ask a prospective health insurance client.

•  1.  What Insurance Company are you insured with and what is the name of your health insurance plan? For example, Blue Cross Blue Shield-"Basic Blue." 

•  2.  What is your Calendar Year Deductible and would you have to pay a separate deductible for each family member if everyone in your family became ill at the same time? For example, the majority of health plans have a per person yearly deductible, for example, $250, $500, $1,000, or $2,500. However, some plans will only require you to pay a 2 person maximum deductible each year, even if everyone in your family needs extensive medical care.  

•  3.  What is your Coinsurance percentage and what dollar amount (stop loss number) is it based on? For example, a good plan design works this way. After you have satisfied your calendar year deductible, the insurance company will pay 80% ($8,000) and you will pay 20% ($2,000) of the first $10,000 in medical bills that you incur each year. This first $10,000 is termed the "stop loss number." After this brief sharing arrangement is over, the insurance company pays 100% up to the Maximum Lifetime Benefit, which is typically, $2-5 Million per insured for the rest of that calendar year. Then, everything starts over again on the first day of each subsequent calendar year. Stop loss numbers can be as little as $5,000 or $10,000 or as much as $20,000. However, be aware that there are some policies on the market that have NO stop loss number at all! Therefore, it is critical that you ask what your stop loss number is before you purchase a plan. 

•  4.  What is your Maximum Out of Pocket Expense per year? Keep in mind that the Maximum Out of Pocket Expenses per year includes all deductibles plus all coinsurance percentages plus all applicable access fees, service deductibles or other fees.

•  5.  What is the Lifetime Maximum Benefit the insurance company will pay if you or someone in your family becomes seriously ill and does your health plan have any "per illness" maximums or caps? For example, some plans may have a $5 Million Lifetime Maximum, but there might be a benefit cap of $100,000 per illness. This means that you would have to develop many separate and unrelated life-threatening illnesses costing $100,000 or less to qualify for the $5 Million of Lifetime Coverage. 

•  6.  Is your plan a Schedule Plan, in that it only pays a certain amount for a specific list of procedures? For example, Mega Life & Health & Midwest National Life, endorsed by the National Association of the Self-Employed, (N.A.S.E.) endorses schedule plans under the name "Health Markets."

•  7.  Does your plan have Doctor Copays and are you limited to a certain number of doctor co-pay visits per year? For example, many plans have a limit of how many times you go to the doctor per year for a copay and, quite often the limit is 2-4 visits.  

•  8.  Does your plan offer Prescription Drug Coverage and if it does, do you pay a co-pay for your prescriptions or do you have to meet a separate drug deductible before you receive any benefits and/or do you just have a discount prescription card only? For example, some plans offer you prescription drug benefits right away, while other plans require that you pay a separate drug deductible before you can receive prescription medication for a copay. Today, many plans offer no copay options and only provide you with a discount prescription card that only gives you a 10-20% discount on all prescription medications. This is a dangerous policy design that can lead to catastrophic out of pocket expenses if you were to contract any one of a host of major medical conditions such as, Multiple Sclerosis or Rheumatoid Arthritis that require expensive outpatient maintenance medications which are usually not available in Generic form. 

•  9.  Does your plan have any reduction in benefits for Organ Transplants and if so, what is the maximum your plan will pay if you need an organ transplant? For example, some plans only pay a $100,000 maximum benefit for organ transplants for a procedure that actually costs as much as $500K or more. In addition, this $100,000 maximum may also include the cost of expensive anti-rejection medications that have to be taken after a transplant. If this is the case, the insured will often have to pay for all anti-rejection medications (a.k.a. Immunosuppressants) out of pocket. Keep in mind that these medications are among the most expensive medications which individuals requiring an organ transplant will have to take for the rest of their life.

•  10.  Do you have to pay a Separate Deductible or Access Fee for each hospital admission or for each emergency room visit? For example, some plans, like the Assurant Health's "CoreMed" plan have a separate $750 hospital admission fee that you pay for the first 3 days you are in the hospital. This fee is in addition to your plan deductible. Keep in mind that many plans have benefit "caps" or "access fees" for out-patient services, such as, physical therapy, speech therapy, chemotherapy, radiation therapy, etc. Benefit "caps" could be as little as $500 for each out-patient treatment, leaving you a bill for the remaining balance if the fee for that particular service exceeds $500. "Access fees" are also additional fees that you are required to pay per treatment. For example, for each outpatient chemotherapy treatment, you may be required to pay a $250 "access fee" per treatment. So for 40 chemotherapy treatments, you would have to pay 40 x $250 = $10,000. Again, these fees would be charged in addition to your plan deductible. 

Now that you have read the list of questions that I ask a prospective health insurance client, ask yourself. How many questions you were able to answer? 

If you were not able to answer all ten, don't be discouraged. That does not necessarily mean that you are not a smart consumer. I am sure you comparison shop for everything else. Maybe you were just extremely confused by all of the insurance terminology or you had a "bad" insurance agent who did not take the time to really explain the type of coverage you were purchasing.  

So how would you know if you dealt with a "bad" insurance agent? Because a "great" insurance agent would have taken the time to help you really understand your insurance benefits and s/he would have answered all of your questions about your health plan purchase BEFORE you signed on the dotted line. 

Remember, insurance agents are not different from any other professional. There are "great" insurance agents and brokers that care about clients and offer exceptional customer service, and then there are "bad" agents that avoid answering questions and typically don't return phone calls when clients leave messages about unpaid claims or skyrocketing health insurance premiums.

Q. How do you know if you have a "great" agent?   

A. A "great" agent will recommend a health insurance plan based on all four variables; wants, needs, risk and cost. A "great" agent gives you enough information to weigh all of your options so you can make an informed purchasing decision. And, lastly, a "great" agent looks out for YOUR best interest and NOT the best interest of the insurance company.

Another way to tell whether or not you have a "great" or a "bad" insurance agent is to determine how many of the ten questions you were actually able to answer without looking at your health insurance policy.

If you were able to answer all ten questions, you have a "great" insurance agent. 

If you were able to answer at least seven out of ten questions, you probably have a "good" insurance agent. But, if you were only able to answer a few questions or less than seven out of the ten, you most likely have a "bad" insurance agent. 

Always keep in mind that your health insurance purchase is just as important as purchasing a house or a car, if not more important. So don't be afraid to ask your insurance agent a lot of questions to make sure that you understand what your health plan does and, more importantly, does not cover.

If you don't feel comfortable with the type of coverage that your insurance agent suggests or if you think the price for the plan is too high, ask your agent if s/he can select a comparable plan so you can make a side by side comparison before you make a purchase. 

And, always make sure that you read all of the "fine print" in your health plan brochure and please remember to take the time to read through your policy during your "10-day free look period." 

Remember, if you don't understand something, or aren't quite sure what the asterisk (*) next to the benefit description really means in terms of coverage, call your insurance agent or contact the insurance company directly to ask for further clarification. Furthermore, make sure you take the time to perform your own research on the Internet. 

For example, if you research Mega Life and Health and Midwest National Life Insurance Company, endorsed by the National Association for the Self Employed (NASE), you will find out that there have been multiple class action lawsuits brought against these companies since 1995. Many health insurance companies, especially the ones that have to pay huge insurance fines often change their name and target more unsuspecting consumers. In fact, today these companies are selling health insurance under the name "Health Markets." 

So please perform your own due diligence and ask yourself, "Is this a company that I can trust to pay my health insurance claims?"

Additionally, find out if your agent is a "captive" insurance agent or an insurance "broker." 

Why?  

"Captive" insurance agents can only offer ONE insurance company's products. In contrast, an "Independent" agent or insurance "Broker" can offer you a variety of different insurance plans from many different quality carriers.  

Over the years, I have developed strong and trusting relationships with my clients and I am constantly developing new clients through existing client referrals. This is partly because of my level of insurance expertise and primarily due to the level of personal service that I provide.

Because personal service is extremely critical to building long-term client relationships, this is the main reason that I caution people to be very careful when using online quoting engines and online applications to buy health insurance on the Internet. 

Again, in my professional opinion, there are too many variables to consider when shopping for health insurance. Therefore, I am a firm believer that a health insurance purchase requires the level of expertise and personal attention that only an insurance professional can provide. And, since it does not cost a penny more to purchase your health insurance through an independent agent or broker, my advice to you would be to use Ebay and Amazon for your less important purchases and to use a knowledgeable, ethical and reputable independent agent or broker for one of the most important purchases you will ever make....your health insurance policy.

Lastly, if you have any concerns about an insurance company, contact your state's Department of Insurance BEFORE you buy your policy. Your state's Department of Insurance can tell you if the insurance company is registered in your state and can also tell you if there have been any complaints against that company that have been filed by policyholders.

Also, if you suspect that your agent is trying to sell you a fraudulent insurance policy, for example, you have to become a member of a union to qualify for coverage, or s/he isn't being honest with you, your state's Department of Insurance can also check to see if your agent is licensed and whether or not there has ever been any disciplinary action previously taken against that agent.

In closing, I hope I have given you enough information so you can become an INFORMED insurance consumer and you can understand why "The Best Policy Is A Great Agent." Whatever decision you make in regards to your health insurance, please always remember to heed the following words of wisdom.  

• "If it sounds too good to be true, it probably is!" ..........and

• "If you only buy on price, you get what you pay for!"

Ten Questions You Should Ask Your Agent Before You Buy A Policy

If you are a business owner, self-employed or an employee of a company that is not offered medical coverage through your employer, you may have to undertake the frustrating, daunting and time consuming task of purchasing health insurance on your own. If this is the case, there are certain things that you can do become an informed consumer so you can ensure that you are purchasing the type of health insurance coverage you really need at a price you can afford.

When you purchase a health insurance plan, it is important that you balance four important variables:
wants, needs, risk and cost, before you spend your money.

Although you may "want" a health plan that offers you 100% coverage and a $5 Copay for prescription medications, you may not "need" this type of health plan if you are healthy, take no medications and do not have any significant health related "risk" factors.

Since a 100% health plan will "cost" significantly more than an 80/20 Plan, it may not be in your best interest to pay higher monthly premiums for 100% coverage if you are currently healthy.

Although no one knows exactly when they will actually use their insurance coverage, considering these four key variables prior to purchasing a health plan is a good rule of thumb.

It is also critical for health insurance consumers to understand that all plans, even 100% Plans, have some form of coverage limitations. Knowing what your policy DOES NOT cover, is more important than knowing what it DOES cover.

Many plans also have a separate deductible for emergency room visits. These deductibles are in place to discourage policyholders from using the emergency room as a doctor's office. Typically, these ER deductibles are waived if the patient is admitted to the hospital. 

The following is a list of 10 key questions that should help health insurance consumers to better understand the coverage limitations of the plans they are considering purchasing. Make sure you ask your insurance agent these questions BEFORE purchasing a health insurance policy. 

•   1. What insurance company do you represent and are you a "captive" agent, "independent" agent or an insurance "broker?" "Captive" agents represent ONE insurance company's products only.

An "independent" agent or insurance "broker," on the other hand, typically represent many quality insurance carriers and can sell a variety of different insurance products without any contractual restrictions.

BEWARE!  Dealing with a "captive" agent may limit your choices, since these agents can only sell that particular insurance company's health plans.

•   2. What is the plan's calendar year Deductible and would I have to pay a separate deductible for each family member if everyone in my family became ill at the same time? The majority of health plans have a per person calendar year deductible, for example, $250, $500, $1,000, or $2,500. Some plans are designed so in a "worse case scenario" only two family members will have to pay their deductible in any given calendar year.

BEWARE! Some plans will require each person in the family to pay their calendar year deductible. This can be a huge financial burden if everyone in the family was involved in an accident or if members of the family became ill at the same time.  Many plans have a separate drug deductible before the plan will pay for any medications. Make sure you know what deductibles you will be responsible for before you buy a health plan.

•   3. What is the plan's Coinsurance percentage and what Stop Loss Number is this percentage based on?  

  These percentages are typically based on a specific dollar amount, known as the "stop loss number." Here's where it get's tricky. Quite often, health insurance plans have different "stop loss numbers".
  I have seen some plans that have a "stop loss number" as low as $2,000 and as high as $25,000 or some with none at all. 

Let's figure out the insured's maximum out of pocket on an 80/20 plan that has a $1,000 deductible and an 80/20 split of the first $5,000 ("stop loss number.")

$1,000 + 20% of $5,000 ($1,000) = A Maximum Out of Pocket of $2,000. 

Now, let's figure out the insured's maximum out of pocket on an 80/20 plan that has a $250 deductible and a $10,000 "stop loss number."

$250 + 20% of $10,000  ($2000) = A Maximum Out of Pocket of $2,250. (Note: Total does not include any separate "service deductibles" or access fees. Many low quality plans also have these.) 

Again, after this brief 80/20 cost sharing with the insurance company, also know as a the coinsurance percentage split, most major medical plans will pay 100% of in-network covered charges up to the Lifetime Maximum amount that is specified in the policy.

BEWARE! Some policies on the market are sold with NO stop loss, but still list a coinsurance percentage. Therefore if you purchase an 80/20 with no stop loss, you will actually be paying 20% of all of your medical bills each calendar year. So unless you want to be responsible for 20% of all of your bills, make sure you find out what the "stop loss number" is BEFORE you purchase a health plan!

•   4. What is the plan's Maximum Out Of Pocket Expenses per year? This expense is a total of all deductibles, plus all coinsurance percentages, plus all applicable "access fees", "service deductibles" or other "fees" outlined in your policy.

BEWARE! Quite often agents neglect to tell prospects about hidden fees, so make sure you have a good grasp on the basics, like deductibles, coinsurance & stop loss numbers. Always ask about additional "fees" BEFORE you purchase the plan!

•   5. What is the plan's Lifetime Maximum Benefit if I become seriously ill and does the plan have any "per illness" maximums or caps? The majority of health insurance plans have a two million or five million dollar Lifetime Maximum Benefit. The Lifetime Maximum Benefit is the maximum amount the insurance company will pay if you or someone in your family becomes seriously ill.

BEWARE! Some policies will stipulate that there is a maximum benefit cap of $100,000 per illness. This means that you would have to develop many separate and unrelated life-threatening illnesses costing $100,000 or less to qualify for the five million dollar Lifetime Maximum Benefit. Mega Life & Health, Midwest National Life a.k.a. Health Markets, formerly U.I.C.I., endorsed and promoted by the National Association for the Self Employed (N.A.S.E) and the Alliance for Affordable Services are known for selling "schedule" plans with "per illness caps."

•   6. Is the plan a Schedule Plan, in that it only pays a certain amount for a specific list of procedures? Some health plans only pay a specific dollar amount for certain procedures, despite the fact that the procedure often cost more than the plan stimulates.

BEWARE! Mega Life & Health, Midwest National Life a.k.a. Health Markets, formerly U.I.C.I., endorsed and promoted by the National Association for the Self Employed (NASE) and the Alliance for Affordable Services are known for selling "schedule" plans.

•  7. Does the plan have unlimited doctor copays or is there a limited number of doctor copay visits allowed each year? Many quality plans have no limit on the number of times you can use your doctor copay.

BEWARE! Several plans have a limit of how many times you can go to the doctor each year for a Copay. Quite often, the limit is 2-4 visits per year.

•  8. Does the plan offer Prescription Drug Coverage and if it does, what type of coverage? Some plans offer prescription drug benefits on both generic and brand name medications right away. Other plans will require you to pay a separate outpatient prescription drug deductible before you can obtain your prescription medication for a Copay.

BEWARE! Today, many plans offer NO outpatient prescription drug Copay options. Typically, these plans only provide the insured with a discount prescription card which only offers the insured a 10-20% discount on prescription medications. This can lead to catastrophic out of pocket expenses to the insured.

•  9. Does the plan have any reduction in benefits for Organ Transplants and if so, what is the maximum the plan will pay out for an organ transplant? The majority of quality major medical plans treat organ transplants as any other illness. This means that the insurance company will cover the insured until the Lifetime Maximum Benefit of the plan is reached. Again, in most cases, this Lifetime Maximum is five million dollars. You should accept no less than one million dollars of coverage for Organ Transplants.

BEWARE! Today, some plans only pay a $100,000 maximum benefit for organ transplants. Plans that offer limited organ transplant coverage are extremely risky, since organ transplant procedures often range in the neighborhood of $350-$500K. In addition, it is not uncommon for a transplant patient to need a second organ transplant. Keep in mind, that the $100,000 maximum payment for organ transplants on many plans also includes the cost of expensive anti-rejection medications. If you have an organ transplant, you will quickly reach the $100,000 maximum benefit, which means that you will be required to pay for costly anti-rejection medication out of pocket. This can lead to catastrophic out of pocket costs to the insured.

•  10. Does the plan have any separate "services deductibles" or "access fee" for each hospital admission or for each outpatient test? Some plans, like Assurant Health's "CoreMed" plan have a separate $750 hospital admission fee for the first three days of each hospital stay. These hospital admission fees may also be called "Access Fees" on other policies. Typically the insured is responsible for paying these access fees for each hospital admission in addition to their calendar year health plan deductible.

BEWARE! "Access fees" and "service deductibles" are separate from your plan's calendar year health plan deductible. Be aware that many plans now have benefit "caps" or "access fees" for out-patient services, such as, physical therapy, speech therapy, chemotherapy, radiation therapy, etc. These "benefit caps" could be as little as $500 for each out-patient treatment, which will leave the insured responsible for the remaining balance that is over $500.

Again, "access fees" are additional fees that you may have to pay per treatment before the insurance company will pay the provider.  These fees can quickly add up. For example, if you need to have 40 outpatient chemotherapy treatments, and you must pay a $250 "access fee" per treatment, you would have to pay an additional 40 x $250 = $10,000.

Remember, purchasing a health plan is the most important purchase you will ever make. Insist that your insurance agent explain to you exactly what your health plan does and does not cover and take the time to read the "fine print" in the plan brochure and ask questions about terminology you don't completely understand.

In addition, when you receive your health insurance policy in the mail, don't just detach your insurance cards and place them in your wallet or purse and then throw your insurance policy in your desk drawer or filing cabinet. Take the time to sit down and read your policy page by page.

Once you receive your policy, you have a 10-day free look period, so if your coverage is not what you thought you purchased, you have time to call the insurance company and cancel the policy without incurring any fees.

Finally, if your being pitched a health plan that seems to good to be true (e.g. all pre existing conditions are covered, the plan is significantly cheaper than all other plans) contact your state's Department of Insurance BEFORE you buy the policy. Your state's Department of Insurance can tell you if the insurance company is registered in your state and can also tell you if there have been any complaints against that company that have been filed by policyholders.

Remember, if you suspect that your being scammed or you think the agent is trying to sell you a fraudulent insurance policy, (e.g. you have to become a member of a union to qualify for coverage) your state's Department of Insurance can also check to see if any prior disciplinary action has been previously taken against that agent.

Don’t Fall Victim To Health Insurance Scams: 10 “Red Flags” You Should Watch Out For

In today's fast paced world, business owners don't often have the time to thoroughly check out the companies they rely on to provide goods and services. In many cases, a determination of product/service quality can be made at the time goods are delivered or services are rendered. If goods or services do not meet expectations, there is often an immediate remedy available.  For example, poor quality goods can be shipped back to the supplier and/or payment for services can be withheld until services are satisfactorily rendered.

Unfortunately, business owners do not always purchase items that are tangible items, in the sense that they can immediately determine the quality of the goods and/or services at the time of purchase. One example of such a purchase is health insurance.  Since health insurance is not usually used immediately after purchase, the quality of care or the legitimacy of the policy may not even come into play until the business owner, or a family member, actually needs to have medical treatment. This is one of the primary reasons that many companies, often appearing legitimate, can get away with selling bogus health insurance coverage to unsuspecting business owners.

In most cases, fraudulent health insurance policies are sold to business owners by telemarketers or "agents" through bogus Associations and Unions. In that, the buyer must join a professional and/or trade association or become a union member to qualify for health insurance. In fact, in a study published by the U.S. General Accountability Office (GAO) in 2004, the GAO found that association schemes ranked at the top of the marketing methods followed by bogus health insurers.  According to the report, "Employers and Individuals Are Vulnerable to Unauthorized or Bogus Entities Selling Coverage, between 2000 and 2002, the U.S. Department of Labor and state insurance regulators identified 144 unauthorized entities selling health insurance unlawfully. These entities defrauded 15,000 employers and more than 200,000 policyholders out of $252 million."

However, it is important to mention that many individual and group health insurance products are endorsed by reputable Associations, such as the AARP and the American Bar Association and, many reputable Unions, such as the AFL-CIO and the Teamsters.  These organizations have long been recognized for bringing a common class of professionals or citizens together for other purposes that have very little to do with health insurance. Membership commonly includes a wide range of other benefits in addition to discounted health insurance. Typically, the organizations have a governing organization, a constitution and bylaws, a set of officers, voting rights, regular membership meetings and a professional code of conduct. 

Unfortunately, most individuals do not find out that they were making hefty monthly payments or premiums to fraudulent Associations or Unions until they have a severe condition that requires medical treatment. Usually, it isn't until after they receive treatment that they receive notice from their medical provider that the claim that was submitted to the insurance company was denied and that all the medical charges that were incurred are now their responsibility.

Often, the scheme starts when business owners are contacted by telephone or approached by someone who claims to represent a certain, official sounding, Association or Union. The business owner is then informed that if s/he becomes a member of the Association or joins the Union, s/he could qualify for a low cost group or individual health insurance plan. Typically the Association or Union is promoted to represent self-employed individuals and small business owners. The low cost health insurance is usually presented as one of the many "perks" that the business owner can qualify for, in addition to many other "member" benefits, like discounts on other services, such as dental, eyeglasses, office supplies, hotels, rental cars, etc. 

In many instances, these bogus companies involve licensed health insurance agents to sell their fraudulent health insurance products. Sometimes the "agents" know the products are fraudulent, other times, the "agent" also falls prey to the scheme.  Often, the schemes prey upon consumers who have been previously declined insurance coverage or suffer from a pre-existing condition. Since these consumers have very limited options to purchase private health insurance coverage, the benefits of an Association or Union membership that offers health insurance coverage for a "membership fee" or "union due" is enticing. To the unsuspecting consumer that has a pre-existing medical condition or is paying high premiums for coverage, the "membership fee" or "union due" is a small price to pay for what they believe will be a quality health plan that provides "guaranteed" coverage with no "pre-existing condition exclusions" and  no "waiting periods."

In many circumstances, the print materials that are left with the consumer are very well designed, however, the majority of the time, the language in the "health plan brochure," if there is one, is very unclear. The literature may name the entity that is authorized to act as the health plan administrator of the plan, but neglect to name the actual insurance company that is providing the health insurance coverage. Unfortunately, it is often difficult for the consumer to separate the illegitimate companies selling official sounding health plans from the legitimate ones. Typically fraudulent health plans have many commonalities. 

Here are 10 "Red Flags" that may indicate health insurance fraud:

•  1.) The "agent" is not a licensed insurance agent but an "enrollment" or "membership" coordinator.

•  2.) The term "discount plan" is written in the product literature, but the term health plan, health insurance or policy is frequently used by the plan promoter. Discount plans often provide nothing more than a discount for medical services, such as prescription medications, eyeglasses, dental, etc.  These plans are not designed to offer major medical health insurance coverage.

•  3.) The official sounding "Association or Union" is one that you have never heard of before.

•  4.) The plan is referred to as an ERISA plan. The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that allows employers to set up employee benefit plans for employees and their dependents. ERISA plans are not subject to state regulation and are not regulated by the state insurance commissioner.  ERISA plans are normally not sold as health insurance, but are instead, established by employers, unions or groups acting on behalf of employers.  Therefore, unsuspecting buyers believe these plans actually offer health insurance coverage, when if fact, they do not.

•  5.) The buyer is told that the "membership fee or union dues" includes the health insurance premium, but there is no mention of the word "premium" in any of the plan literature.

•  6.) The plan offers "guaranteed" insurance coverage with no exclusions for "pre-existing conditions" and no "waiting periods."

•  7.) The plan is significantly cheaper in price than other health insurance plans.

•  8.) The term "reinsured" is used in regards to the plan. Reinsurance is something insurance companies buy to protect themselves against their own risks. It is insurance for insurance companies. Licensed insurers rarely have their agents mention any of their reinsurance arrangements during a sales presentation.

•  9.) The Association or Union is comprised of members from all walks of life and/or requires its members to state that they belong to a certain trade, class or group of professionals that they have no affiliation with, for example, the Association or Union is said to be comprised of "Food and Beverage" workers, but "Florists" and "Machinists" are allowed to enroll as members.

•  10.) If the Association or Union is said to have a special arrangement with a health insurance company, a plan administrator or another third party that has designed the plan using a legal "loophole" that allows members to purchase health insurance at a discounted rate or to purchase a individual or group health insurance policy.

So how can you protect yourself from falling victim to a fraudulent insurance scam?  Make sure you contact your state's department of Insurance to determine if the health insurance company and the third-party administrator are licensed to do business in your state and make sure that the "agent" selling the plan is a "licensed health insurance agent."  Additionally, make sure that health insurance company has been approved to sell the particular policy that is being offered.  Since it may be difficult to tell if fraud is involved, always put off buying your health insurance policy until you have had the opportunity to perform your own due diligence.

My name is C. Steven Tucker and I have been a multi state licensed health and life insurance broker for almost 15 years now. One of the biggest challenges I have had to deal with through the years has been trying to help the uninsurable. Unfortunately in most states if you have one of a host of "pre-existing" medical conditions you are labeled as uninsurable on an individual health insurance policy. In most states this uninsurable status lasts for many years and sometimes for life depending on the specific pre existing condition you have been diagnosed with. Some of the pre existing medical conditions that render an applicant uninsurable for ten years or more are:

Heart Attack
Stroke Diabetes (insulin or sugar pill dependant)
Cancer (Infiltrating Ductal Carcinoma only, Carcinoma in site ok after excision)
Lupus
Multiple Sclerosis
Muscular Dystrophy
Degenerative Arthritis

and a host of other pre existing conditions. In addition, there are applicants who have a combination of controlled pre existing conditions but because they have more than three "rate-able conditions" they are labeled uninsurable. For example, with many carriers an applicant who has Hypertension & Hyperlipidimia but is also overweight falls under the "3 strikes your out" rule and is labeled uninsurable. Or an applicant may have two of the aforementioned controlled conditions and is not overweight but is a smoker and is then labeled uninsurable also. Or an applicant who has asthma but also smokes falls in to the same uninsurable category with many carriers. 

This is just a small snippet of conditions or "combo conditions" that can render an applicant uninsurable. The question then becomes, what do I do now? Who will insure me against the catastrophic medical bills that I may face in the future? Who will help me pay for the medications I currently am taking to control the aforementioned conditions? For many years depending on the state you live in you only had two options. They are as follows: 

1.) If you have a corporate tax i.d. number you can purchase a small group health insurance policy from most insurance carriers. With this scenario a minimum of two people (often husband & wife) who work for the same corporation can apply for a small group health insurance policy. After a period of time, or in some cases immediately (depending on how many months you have had prior health insurance coverage without a lapse) pre-existing conditions will be covered provided that they are a covered expense on the policy.

2.) Enroll in your states insurance risk pool (if your state is fortunate enough to have one). In our home state of Illinois the risk pool is called the Illinois Comprehensive Health Insurance Plan (ICHIP). ICHIP is a state health benefits program and not an insurance company. Persons must qualify for coverage but in most cases if the applicant is coming off an exhausted qualified COBRA continuation plan from a prior employer sponsored group, their pre existing conditions will be covered from day one (provided again that those conditions are a covered expense on the ICHIP policy). However, ICHIP (and all insurance risk pools) are by no means entitlement programs. They are far from free! Premiums charged are established by law at from 125%-150% above the average rates charged individuals for comparable major medical coverage by five or more of the largest insurance companies in the individual health insurance market in that state. Suffice it to say, the premiums are far from affordable for many people. The rates for a person 50 years of age living in Chicago can range from $554 monthly for a $5,200 deductible plan to $852 monthly for a $500 deductible plan. For those who do not have an insurance risk pool in their state (http://www.naschip.org/states_pools.htm) their options are then even more limited if they are labeled as uninsurable.

There is now another option. American Medical & Life Insurance Company of New York, New York is now offering Defined Benefit Health Insurance Policies to the uninsurable. There are only three restrictions to obtaining these quality Defined Benefit Health Insurance Policies. They are as follows:

1.) You may not be a Medicare recipient.
2.) You may not be receiving disability benefits.
3.) You may not be receiving workers' compensation benefits.

There are no other underwriting requirements. This means that regardless of your pre existing condition American Medical & Life insurance company will issue you a Defined Benefit Health Insurance policy.
 
What exactly is covered by their Defined Benefit Health Insurance policies? There are four different Defined Benefit Health Insurance Policies to choose from.
I will list the benefits covered on the best of the four different plan options. They are as follows:

All benefits are provided on a "first dollar" basis (no deductible or co pays required)
$1,000 per day covered for the first 100 days of hospital admission
$2,000 in additional coverage for the first day of hospital admission
$1,000 in additional coverage for the first 15 days of Intensive Care or Critical Care
Unlimited inpatient our outpatient Surgical Benefit provided on all plans
One Preventative Care Visit covered per insured per calendar year with a $150 allowance per visit
Up to 7 outpatient doctor office visits included with the with no co pay or deductible required
Mail order Generic & Brand name medications are discounted at up to 50%
Medically necessary diagnostic tests and x-rays performed in a doctor's office or outpatient facility (e.g. MRI, CAT Scan, EKG, Mammo) are covered up to $400 per visit with 5 visit annual allowance
 
There is a 12 month waiting period for Pre Existing conditions. However, because the plan is HIPAA compliant this waiting period will be waived if you have a Certificate of Creditable coverage from another health insurance plan showing 18 months of prior coverage with no lapse more than 63 days
$5,000 of Critical Illness coverage provided for Primary Insured & Spouse (optional on other 3 plans) 
Nationwide P.P.O. network (www.multiplan.com)

Arguably these benefits rival the "first dollar" benefits provided on most major medical health insurance policies on the market today. The most attractive part about this kind of health insurance policy is that the premium required is well below half the premium required for the ICHIP state insurance risk pool. Also like the state insurance risk pool coverage these Defined Benefit Health Insurance policies are fully HIPAA compliant. This means that if you are coming off of an employer sponsored Cobra continuation plan and can produce a certificate of creditable coverage from this prior carrier showing 18 months of prior coverage with no lapse of more than 63 days your pre existing conditions will be covered from day one. If not, there is a 12 month waiting period for pre existing conditions.

Whilst a major medical health insurance policy is always the best way to insure oneself against the catastrophic medical bills one can experience throughout their lifetime, a Defined Benefit health insurance policy is most certainly a cost effective way to protect oneself if you are rendered uninsurable on the individual health insurance market.

Without a doubt, this is the finest Defined Benefit health insurance policy on the market today. Most especially since the majority of other offers to the uninsurable consist of discount P.P.O. network memberships that are by no means health insurance policies. We've all seen them advertised from company's like "Care Entree" or "Ameriplan" that offer "health coverage" (clever way to circumvent the words "health insurance") that will "cover" the entire family for $89 monthly!

This "coverage" is so inexpensive because it provides nothing more than a P.P.O. repricing discount. This in itself is not a bad thing. However without a Major Medical or Defined Benefit health insurance policy in place one can experience catastrophic medical bills with these types of "health coverage" plans. This is the case because the average P.P.O. discount on medical procedures performed within a P.P.O. network is between 25% & 40%. For a $100 doctor office visit, this is a good deal. However, if the medical bill is $500,000 that can leave the "covered" person with as much as $200,000 in out of pocket expenses!

For more information about Guarantee Issue Defined Benefit Health Insurance Plans and or Major Medical Health insurance plans please visit click here: http://www.sbisvcs.com/guarantee_issue.htm

To check out the rates and to apply online for the aforementioned Defined Benefit Health Insurance plans offered through the Association for Independent Managers (AIM) please click here: aimhealthplans.com Plans are underwritten by American Medical and Life insurance company of New York, New York (www.usamli.com) available in 50 states.
 

Mega Life and Health Markets Finally Get What They Deserve!

This is a great day in the health insurance industry! Rarely is an insurance company held liable for improper conduct. The majority of the time the "Big Guy" takes advantage of the "Little Guy." Sadly, the "Little Guy" often has no recourse. But this is not the case as of July 24, 2008.

After many years of repeated violations of insurance conduct laws the National Association of Insurance Commissioners (NAIC) helped levy one of the largest market conduct fines in insurance history against Mega Life & Health & Midwest National Life a.k.a. Health Markets, formerly U.I.C.I. and endorsed and promoted by the National Association for the Self Employed (NASE) and the Alliance for Affordable Services. 

In my opinion, after warning consumers for years about these companies, the $20 Million Dollar Fine they received is not nearly enough and it has come much too late!

Health Markets is still slinging their garbage plans in many parts of the country and hundreds of innocent consumers who purchased a plan through the National Association for the Self Employed call me each week to tell me that they had no idea about the extreme limitations included in the "insurance coverage" provided by Mega Life & Midwest National Life. 

Many consumers were not even aware that the plans they purchased were "schedule plans" and in many instances, only paid out $100,000 per illness. Misleading? Sure. In fact, during the sales process, the emphasis seems to be on the one million or two million lifetime maximum and NOT the $100,000 per illness maximum. 

Something that many consumers also didn't understand about these plans is that many did not have a
"stop loss number." 

To understand what a "stop loss number" is exactly, let's take a look at the three main parts of a health insurance plan: 
 

1. Calendar year deductible: This is the amount the insured pays first, before the insurance company shares in any medical expenses that are not covered on a "first dollar" basis.

2. Coinsurance: This is the percentage the insured pays of a specific dollar amount of medical bills incurred throughout the course of each year, called the "stop loss number" before the insurance company pays $100 of the medical costs.

3. Stop Loss Number: This is the dollar amount of medical bills that the insurance company agrees to share with you, each year, before they will pay 100%. 

The average insurance consumer is usually familiar with the deductible. Deductibles can range from $250 to $10,000. Typically, the lower the deductible, the more expensive the plan, because the insurance company is assuming a greater risk. 

The same holds true for the Coinsurance. Health plans are sold with different Coinsurance percentages. Plans can be 50/50, 70/30, 80/20, 90/10 or 100% or a variation. These numbers refer to percentages. The first number (e.g. 80/20) refers to the percentage the insurance company will pay, usually for in-network charges after the insured meets his/her calendar year deductible. The second number (e.g. 80/20) refers to the percentage the insured pays. 

These percentages are typically based on a specific dollar amount, known as the "stop loss number." Here's where it get's tricky. Quite often, health insurance plans have different "stop loss numbers".
I have seen some plans that have a "stop loss number" as low as $2,000 and as high as $25,000 or some with none at all. 

Let's figure out the insured's maximum out of pocket on an 80/20 plan that has a $1,000 deductible and an 80/20 split of the first $5,000 ("stop loss number".)

$1,000 + 20% of $5,000 ($1,000) = A Maximum Out of Pocket of $2,000. 

Now, let's figure out the insured's maximum out of pocket on an 80/20 plan that has a $250 deductible and a $10,000 "stop loss number."

$250 + 20% of $10,000  ($2000) = A Maximum Out of Pocket of $2,250. (note: total does not include any separate "service deductibles" or access fees. Many low quality plans also have these.) 

Again, after this brief 80/20 cost sharing with the insurance company, also know as a the coinsurance percentage split, most major medical plans will pay 100% of in-network covered charges up to the Lifetime Maximum amount that is specified in the policy. 

On quality comprehensive health insurance plans, the Lifetime Maximum benefit is usually five million dollars. Typically, plans from reputable health insurance carriers do not have a "$100,000 per illness" or reduced benefits for other medical treatments, like Organ Transplants. 

Unfortunately, it is only when an unsuspecting insurance consumer develops a life threatening medical condition that they find out that on the 80/20 plan they purchased, they are responsible for paying 20% of the medical expenses up to the Lifetime Maximum (e.g. 20% of One Million Dollars or $200,000.). In addition, if they have a $100,000 per illness cap, they will also be responsible for all of the medical expenses that exceed $100,000. 

Would you buy a policy like that if it was fully explained to you? Most definitely not, and the NAIC apparently agrees. This is one of the reasons why after a 3 year, 29 state investigation, Mega Life & Health, Midwest National Life a.k.a. Health Markets, formerly U.I.C.I., endorsed and promoted by the National Association for the Self Employed (NASE) and the Alliance for Affordable Services finally got what they deserved!

For more information, you can also read a scathing Market Conduct Report, which was included in the fine to warn future innocent consumers.

If you or a loved one have fallen "victim" to any of this organizations  or have been approached by an agent selling one of these "insurance products" please feel free to contact me for help and advice.