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Team SJB Tips

An Ounce of Prevention

It is no secret that the health care industry has changed dramatically since the implementation of the “Patient Protection and Affordable Care Act (PPACA).” Some key changes we have seen are hyper-inflated premiums, new policy structure and a major shift in the way medications are covered.

Today, all policies must include items and services within at least the following 10 categories known as “Minimum Essential Benefits” as mandated by the PPACA:
ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

A couple of major issues we find with the some of the mandated benefits are that not everyone needs such benefits as maternity or children’s dental and vision care. Moreover, these benefits may not be removed from the policy. In some cases the benefits are more of an illusion at best as the deductible must be satisfied before benefits are payable. With the Administration changing hands it will be interesting to see what adjustments – if any – will be made to the PPACA.

In my opinion however, we cannot simply the lay blame of the current state of our healthcare system at the feet of our Government as there are many factors lending to its demise. An article from October of 2012 on PBS NEWSHOUR by Julie Appleby and Kaiser Health News says the U.S. spends more on health care services than any other country, exceeding $2.6 trillion dollars each year (2014 research statistics by CMS.GOV show a 5.3 % increase in that spending). Below are seven ways we and our medical providers play a role:

• We pay our doctors, hospitals and other medical providers in ways that reward doing more, rather than being efficient
• We’re growing older, sicker and fatter
• We want new drugs, technologies, services and procedures
• We get tax breaks on buying health insurance
• We don’t have enough information to make decisions on which medical care is the best for us
• Our hospitals and other providers are increasingly gaining market share and are able to demand higher prices
• We have supply and demand problems, and legal issues that complicate efforts to slow spending
According to a 2015 survey conducted by the Organization for Economic Cooperation and Development OECD and a comparable report by the National Research Council (NRC), America’s Health “Americans are near the bottom in nine key areas of health: obesity, infant mortality and low birth weight, injuries and homicides, teenage pregnancies and STD’s, HIV and AIDS, drug related deaths, diabetes, heart disease and disability when compared with other “rich” countries, and we are falling behind on life expectancy too. In fact, research shows the health of Americans is worsening even as other countries improve. The U.S. ranked #26 out of 34 countries surveyed.”

Folks, this should be a wake-up call. It’s time we as individuals take a prominent role and become proactive about our health and well being by taking advantage of the preventive benefits found in our health insurance plans. All of these benefits are mandated. Below are the hyper-links to a complete drop-down list of preventive services in each category:

For All Adults
For Women
For Children
As Benjamin Franklin once said “An ounce of prevention is worth a pound of cure.” Although Mr. Franklin was actually referring to fire safety – when it comes to our health – the same holds true and should not only be applied to the way we view our health insurance policies, but how we perceive our own personal health status as well. Let’s resolve to be part of the solution and not contributors to the problem.


Marcella Martucci