I moved to Japan immediately after graduating from college, so for the first ten or so years of my professional life my only exposure to health insurance was socialized Japanese health care.  When I began working on my own in Tokyo, I was initially shocked that I didn’t have a choice of vendors, and that my monthly payment was more like a tax than the purchase of a service.  I avoided paying for awhile.. at least until the government started sending me scary looking warnings in a gigantic red Japanese font (seriously, like a 200 point font).  I relented and paid.  In hindsight I’m glad that I did:  I started actually using the health care system.  It was inexpensive and straightforward.  I took better care of myself.

When my wife and I began the process of moving back to the US, my father nervously admonished me about getting health insurance as soon as possible.  I thought this a bit odd, but didn’t dwell on it.   I figured that the miracle of capitalism would provide us with a smorgasbord of inexpensive, high quality health care options.  Besides, if that didn’t pan out, I was sure that whatever the the national plan was, it would be fine.  I put it off.

On a return trip to the US I stopped by the hometown insurance agency ready to review the rich bounty of health care options due to me as an American.  The hometown agency listened, looked at me like I had two heads, and then gently sent me on my way.  As someone self-employed, they said, my only option in the state of Massachusetts was Blue Cross Blue Shield.  Blue Cross Blue Shield?  The geezer company with the dodgy Vitruvia Man/Staff of Asclepius double logo thing?   What the heck?   Where’s my laundry list of super affordable health insurance options from modern companies with cool logos??  I put it off again and went about my business.

Finally, a month or two before we were scheduled to move back  — about the time we finally learned how to sneak my wife past Homeland Security — I caught a 60 Minutes report on hospital pricing and the uninsured.  The obvious dawned on me:  In the US, unlike Japan, one is not automatically insured.  There’s no national safety net.  You don’t purchase a health care plan that you think is better than the national health care plan, you purchase a health care plan because there is no national health care plan. Holy crap!  I finally understood what my father was talking about.  If I didn’t get insured immediately, an injury could potentially bankrupt my wife and I.  Or even my parents.  No wonder my father was nervous.

I called Blue Cross Blue Shield the next day.

Back then, in 2006, Massachusetts did not require health care insurance.  The selection Blue Cross Blue Shield provided for the self employed was limited to four simple plans.  At the time I was just discovering the brilliance of Health Saving Accounts (HSAs), so I selected a high deductible plan that was HSA compatible.  Although I wound up paying for all of our own moderate medical expenses for the next year, care was not nearly as expensive as if I had not been on health insurance, and the HSA turned out to be a great way to save money while reducing taxes.  All good.

Earlier this year, however, two important things happened:  1. health care reform in Massachusetts, and 2. the upcoming birth of our first child.   Both require significant changes to how I have been managing our health care.  Hence, this blog entry.

I started this as an anecdotal note about what to consider when switching from pre-reform Blue Cross Blue Shield health insurance to post-reform insurance.   I figured I would post a few questions, do some research, and answer them.  Notes to self, plus maybe useful information for someone else.

The number of individual plans offered by Blue Cross Blue Shield of Massachusetts has gone from four to roughly fifty.  Wow.  Yet while there may now be a veritable bounty of health care options available to folks like me, no one seems to understand how they work.  A few questions has become dozens.

Hopefully this unorganized mini FAQ about choosing a plan with Blue Cross Blue Shield in Massachusetts will be useful to others.  If you have any additional questions, feel free to shout out a comment.  Better yet, call the Blue Cross Blue Shield 800 number and ask.  The sales agents are generally quite helpful.  (That said, knowledge about the plans and the system itself seems to vary rather drastically from agent to agent.  If you unsure about some of the answers you’re getting, call back to the main switchboard.  You’ll get a different agent; ask again.)

About a month ago I ran my second marathon in seven years, the Mount Desert Island Marathon in Bar Habor, Acadia National Park, Maine.

The MDI Marathon is famous for being one of the most beautiful marathons in the world.

It’s also famous for being one of the more difficult.
And painful.

Nevertheless, I was pleased with my performance.  I didn’t set any records, nor did I come close to my goal time of four hours.  I did, however, finish in the top third of participants (it really was a tough course) running a race for which I trained and completed — for the most part — according to plan.

I also even kind of enjoyed it.  The course truly is beautiful, and the weather couldn’t have been nicer.  Quite a difference from my last race where it rained so hard we were wading knee deep though flood water!

Anyway, here are some things I’ve learned, as a casual runner, from two very different, extremely challenging races.

1.  Come up with a plan and stick to it.

Of course, this goes for just about everything in life.  And I tend to be consistently bad at doing this.   But hey, at least I’m consistent.

In my opinion, the trick for marathons is to come up with a plan and track your results religiously.  You don’t necessarily have to stick to the plan..  Just try to come close.  Everyone gets busy and, as the miles add up, it’s easy to fall off the wagon.

I only half-heartedly tracked training for my first marathon.  Looking back through sparse running logs, I see now that I came nowhere close to the plan I was supposed to be following; even though I had felt I was training  intensely.  This year I achieved maybe 80% of my training goals, went into the race apprehensive, and yet ran far better than I did when I was seven years younger and a stone or two lighter.

Was I in better shape this year?  Probably not.  But I knew clearly what kind of shape I was in relative to my training ideal.  I knew what I was capable of relative to my original plan, and ran the race accordingly.

2.  Start hard and give yourself plenty of leeway.

I tend to cut things close and, no surprise, training has been no different.  Four months prior to the race, as I was just starting to get back into shape, it felt as though I had all the time in the world.  By the time I had six weeks to go, my training log made it perfectly clear that I was flirting with disaster.  And then suddenly I was off for a week with the flu.  Woah.

Though I was able to bump up my number of weekly runs as well as sharply increase average distance… it was painful, and certainly a bit risky.  In retrospect, I would not have had this problem had I not taken it so easy during the early days of training.  Rather than start with challenging distances, I started with low mileage runs.  In other words, I procrastinated doing the real training.  I didn’t push myself until a month into the training.

For the next race I plan to do myself a favor and start real training right away:  Starting from the peak of my ability,  and covering maximum mileage well in advance of the race.

3.  Go the distance while training.

There are a number of marathon training guides out there that recommend limiting long distance runs.  One popular heuristic is “If you can run eighteen miles, then you an run a marathon.”

While I can attest that this is true — this is the maximum distance I trained on before running both of my races — I do feel that to run your best, it’s important to run some mileage that’s a little bit closer to actual race mileage.  After all, eighteen miles is less than two thirds of a marathon.

I recommend training on at least a couple of twenty-two plus mile runs.  This is an incredible confidence booster, and should give you all the feedback you need about how you will perform over the actual race in it’s entirety.  For me, the last four miles tend to be on auto pilot:  a long, slow stride through a haze of adrenaline.  My goal, then, is to train so that I can get to where the adrenaline takes over, and eighteen miles is way too soon.

4.  Train for both distance and strength.

Seven years ago I focused on speed, running lots of short, intense workouts interspersed with only the occasional day of high mileage.  This year I focused on mileage with virtually no speed work.  In both cases I avoided strength training to maximize, instead, the number of runs.

The first marathon taught me, the hard way, the value of gaining stamina through actual experience.  Since I hadn’t training on anything longer the seventeen or so miles, I struggled painfully through the middle of the race, stopping and starting almost every ten minutes.  It still surprises me that I was able to keep going.

This year, although I avoided the mistake of not going the distance while training, and while I had no trouble finishing the race, I found myself stuck in an increasingly sluggish stride.  By mile twenty three I had virtually no strength left. And at mile twenty-five, breathing comfortably, surprisingly full of energy,  I could not for the life of me convince my legs move any faster.

For the next race I plan to mix distance training with quite a bit of weight work, and finish the race with enough stamina and strength to ensure that I can stride, rather than stagger, across the finish line.

5.  Plan to hit the wall.

Last week I discovered that it is possible to run a race and not hit the wall.  This thanks to how extraordinarily well organized the MDI Marathon is.  Gatorade and water available every two miles.  A GU Energy Zone just past mile fifteen.  And all along the route residents were passing out free treats.  (The Fig Newtons I grabbed at mile eighteen really hit the spot!)

Now, I haven’t exactly run a lot of races, but I think this kind of service might be rather unusual.

I learned during race number one that I will likely hit a wall, and that the wall is probably lurking around mile seventeen or so.  The solution?  If you’re not running MDI, plan.  Have a plan to hydrate and get electrolytes and energy back into your body.  Try to stay hydrated throughout the race.  The rule of thumb:  if you wait until you’re thirsty,you’ve waited until it’s too late.

As for me, I make sure to down 20+ ounces of Gatorade an hour or so before the race, and carry an emergency pack of energy gel.  I know that loading up on a sports drink will generally last me through about mile sixteen or so; by which point I expect to have passed at least one or two water stations.  Seven years ago, however, I wasn’t able to get any kind of energy drink until around mile twenty-one.  The sudden performance pick-up after gulping three cups of Gatorade was — no pun intended — staggering.  Carry your own supply of energy gel to help with races like this.

Conclusion

I believe that finishing a marathon is an achievable goal for anyone.  And while there are a number of good books out there for amateur runners, the above simple advice could have saved me from learning some painful lessons the hard way — literally.

Tomorrow, I am going to eat this:

It’s from KFC. Who not too long ago reduced their name to a mere three letters in a coy attempt to appear somewhat less devastating to the human digestive system. Apparently they have dispensed with such nonsense.

If I survive, I will report back.

And then I will go on a fast.

Update: So apparently the sandwich is only available in Nebraska and Rhode Island right now.  I guess corn wranglers and mafioso are the target demographic.

This is excellent. How to fight back against the Nutritional Industrial Complex.

Two-thirds of ad budgets go to heavily processed foods.

“If you can’t still your mind, then fill it with what you would like to experience.”

Within reason I suppose. This could be easily abused..

Excellent video from the Fluoride Action Network.

The fluoride thing has been on my radar for quite awhile. I’m finally getting serious about it.

In a nutshell: The limited benefits of pharmaceutical sodium fluoride are achieved via topical application. Fluoride does not work systemically. Yet adding fluoride to public water supplies amounts to the unethical and uncontrolled medical dosing of entire, non-consenting populations, each individual of which consumes and reacts to the fluoride drug differently. The effects are generally adverse.

Given recent studies showing a link between fluoride intake and loss of IQ, conspiracy theorists will argue that fluoridation is a deliberate and ongoing attempt at “population management”. Considering, however, that it is not pharmaceutical grade sodium fluoride being added to the water, but hydra fluorosilicic acid — a fertilizer phosphate industry waste — I think we’re simply seeing the result of capitalistic status quo: a sixty year plus way of turning a profit on expensive industrial waste.

It’s just that, in this case, the human kidney serves as the waste treatment plant. For a neurotoxin.

Now I need to figure out if any of my favorite beers are made from spring water. Cheers.

How timely. I guess Douglass Kennedy is also having trouble with his precious bodily fluids.

Loved the lead article from Dr. William Campbell Douglass this week. An example of corporatism at it’s very worst.

It’s the kind of gift I wouldn’t give my worst enemies: A flu-shot gift card.

Drug-store chain Walgreens is running radio ads for these things, an ugly reminder that there are only so many more shopping days left until that panic-filled time of year known as flu season.

For just $30, you can doom a loved one to an unnecessary and dangerous experiment — especially since the upcoming seasonal shot will incorporate the unproven and poorly tested swine flu vaccine that had people falling over, dropping dead and coming down with all kinds of illnesses and nerve disorders over the past year. (Read more here.)

I dropped in on a Walgreens to see what this thing looked like. It has a big red heart on it, implying that a flu shot is either good for your heart (it’s not) or that whoever’s giving the card loves you.

But if you really love someone, give them the gift of truth — tell them to stay away from these vaccines and practice good hygiene and common sense instead.

A gift that keeps on giving.

Please don’t pay big pharma for the privilege of testing unproven, experimental concoctions on you or your loved ones.

Here’s some good news: A clinical trial led by Mitsuyoshi Urashima and conducted by the Division of Molecular Epidemiology in the the Department of Pediatrics at the Jikei University School of Medicine Minato-ku, Tokyo found that vitamin D was extremely effective at halting influenza infections in children. The report, published in the American Journal of Clinical Nutrition, follows up on a hypothesis posed over three years ago that deficiencies in the “sunshine vitamin” may leave those deficient susceptible to infections, and this includes the flu.

Ironically, most people in the developed world are chronically deficient. Which isn’t surprising given lifestyle and constant fear marketing about how the sun is out to get us.

So forget about the big pharma vaccines, get some sun and drink your milk, raw if you’ve got it. And remember, when it comes to flu vaccines and “herd immunity,” really it’s a herd of lemmings that big pharma is after..

In the the below please note that Blue Cross Blue Shield is abbreviated “BCBS” and that Blue Cross Blue Shield of Massachusetts is abbreviated “BCBSMA”.

Q: In general, where can I learn more about available health care plans if I am uninsured?
A: Check out the Commonwealth Connector.

Q: How different is the BCBS provider network from plan to plan?
A: Difficult to get a straight answer on this. BCBS agents recommend searching the plan/network you are considering via “Find a Doctor” on the bcbsma.com website. Be warned that there is no direct correlation between the list of plans under “YOUR PLAN’S NETWORK” and the actual names of all the new plans. If you are looking at the various HMO plans, your best bet is to sift through the providers listed in the “HMO Blue” network.

Q: Does coverage change from plan to plan?
A: In general coverage seems to be about the same (from my still rather shallow analysis) however the manner in which services are covered varies drastically from plan to plan. Holistic health services such as chiropractic services may or may not be covered from plan to plan. Check.

Q: Different plans seem to be applied to different calendars. What is the difference between “plan year” and “calendar year”?
A: As you might expect, calendar years start from January 1st. Plan years start from the the day you purchase them. It might be unwise, therefore, to purchase a deductible calendar year plan in November.

Q: How do you change from “couple” to “family” plans?
A: Upon the birth of a child, simply call the number on your insurance card and they will add the new family member. Rates will adjust from that day. (Expect your rate to go up 35% or more when switching from couple to family!)

Q: What’s this thing about pharmacy benefits being required from 2009?
A: This is a question that the BCBS sales agents often can’t answer. In Massachusetts, plans from January 1, 2009 must include pharmacy benefits. If you are on a plan that does not include pharmacy benefits, you may be charged a tax penalty. (Sheesh.. talk about a windfall for the pharmaceutical industry.)

Q: My current claim summary shows “Amount Charged” and “Amount Allowed” columns. What is the difference between these?
A: “Amount Charged” is the amount that the hospital would have billed you had you walked in without insurance. “Amount Allowed” is a lower price the hospital and BCBS have negotiated.

Q: The claim forms make it look like “Amount Allowed” is what BCBS has already paid on my behalf. You mean that it’s actually just a lower, agreed-upon price?
A: Yes. And it differs from hospital to hospital. Moreover, this is what 60 Minutes and other news programs are talking about when they report on problems with hospital pricing. When you purchase a health insurance policy in the US, often what you purchase is their bargaining clout.

Q: If I potentially want to plan for medical expenses, how can I know what the negotiated price is in advance?
A: You can’t. There seems to be no way to learn these agreed upon costs in advance. You can, however, purchase a plan with a higher monthly premium that does not have deductibles but, instead, has fixed copays per incident.

Q: Is there any way to know how much I might pay for a medical expense without insurance?
A: Yes, actually. BCBSMA has two health care cost calculators available from the Member Self Service page. Click on either “Treatment Cost Estimator” or “Treatment Cost Advisor”. The Advisor is from Subimo and generates “in network” versus “out-of network” estimates. The Estimator is from Benefit Nation (which would appear to have a defunct website) and generates national estimates. The two seem to be fairly close, though the Estimator produces weird stats, such as “only 67% of women use a hospital for birth”. Huh?

Q: How are “Out-of-Pocket Maximums” different from “Deductibles”?
A: A “deductible” is the amount you have to pay before BCBS will render coverage. If you have a $5,000 dollar deductible, then you personally have to pay $5,000 before BCBS will cover you. An “out-of-pocket maximum” is the maximum you would “copay” if you were on a non-deductible plan. So if you had to share in the payment love for every expense, say $25 for every doctor’s visit and $500 for a hospital stay, and your out-of-pocket maximum is $1,000, then once you have paid $1,000 for the year, BCBS takes over payments completely. (Note that there seem to be some hybrid plans that have both deductibles as well as copays/out-of-pocket maximums.)

Q: If I switch from one deductible plan to another, does the amount that goes towards my deductible carry over?
A: No. Be very careful here. Plans “refresh” when you change them and any amounts that would have gone towards your deductible are reset back to zero. Switching from a plan with a deductible to a non-deductible plan also, of course, means that you will lose any money already paid towards your deductible. (The sales agents are rather reluctant to explain this..)

Q: Does BCBS provide benefits after one person meets their deductible, or does everyone on the plan have to go over the deductible before BCBS will take over?
A: This seems to depend on the plan. If it is a couple plan, in general it seems as though benefits are provided on a per-individual basis. In some of the newer plans I have noticed this disclaimer: “The entire family deductible must be satisfied before benefits are provided for any one member enrolled under a family membership.” So, think carefully about high deductible family plans.

Q: Speaking of deductible and non-deductible plans, why would I chose one over the other?
A: Good question.

1. If you are young and healthy, chances are you will not spend much time in the doctor’s office. In that case go with a deductible plan: On the off chance that you do get sick, it’s a safety net. You know your maximum possible medical expenses for the year and, most likely, you won’t spend it. Take that money and what you would spend on expensive monthly premium and invest it in an HSA instead.
2. If you expect to require considerable medical care, a plan with a higher premium and no deductible may be more suitable. This is especially useful if you know you have a large medical expense coming up. It’s nice to know, for example, that the max you will pay on that expensive little bundle of joy being born will only cost $500, rather than the five or six thousand dollars the hospital would bill you directly.

Q: But wait.. speaking of HSAs, which plans are HSA compatible?
A: Only four! And I personally have received details on just three. Ask for the “Saver” plans.

Q: Exactly what does “HSA Compatible” mean?
A: This was interesting. The agents at BCBS didn’t seem to know; they just knew that a plan was “compatible” or not. I called my HSA provider (HSA Bank) and got this answer: “The plan itself must explicitly state that it is an HSA compatible plan. If you switch from an HSA compatible plan to a non-compatible plan, you can use your HSA account through the end of the year and then must close it.” Woah, glad I checked.

Q: Some of the HSA compatible plans require a “Utilization Review”. What is that?
A: Actually, all plans require this, though only a few of the Saver plans seem to explicitly mention it. Utilization Review is a department within BCBS that reviews claims, presumably for fraud.

Q: When switching plans, does BCBS provide the alternative coverage immediately, or is there a transition period?
A: Alternative coverage can take over as immediately as you want; I requested that my new plan take over on that day. (I was particularly interested in this issue since, when I first signed up in 2006, I was limited to only emergency medical coverage for the first year! Seems this restriction is no longer in effect.)

Q: How often can you switch plans?
A: Once per year on renewal. Exceptions can be made for subscribers who experience financial difficulties and need to move to lower priced plans.

Q: What plans have a lifetime maximum?
A: Since health care reform, seemingly none. My plan from 2006 had a lifetime maximum of a million dollars; this would appear to be somewhat anomalous.

Q: Is there any significant difference between “individual” and “self-employed” plans?
A: Yes. Plans for those who declare themselves as self-employed may be cheaper than “individual” plans depending on the work you do. Ask.

Q: How did you find out about the self-employed plan thing?
A: There was an option in the toll free call tree for “self-employed plans press one; individual plans press two”. I couldn’t find information anywhere else on the website about self-employed plans so I asked.

Q: If I change plans, when does the new plan go into effect?
A: For individual plans, immediately on the day of plan purchase, or a future date that you request. Self employed and/or small business plans may take up to thirty days.