For any business, the internet is both a boon and a curse. It can be easy to generate word-of-mouth in favor of a new product or service. Unfortunately, there are an alarming number of ways in which that word-of-mouth can turn negative and what was a great launch can soon be falling out of the sky in flames. This is not just the buzz on the social network sites. A part of the problem lies in the number of review sites like Yelp or those more clearly associated with negative comments. It is easy for someone disgruntled, whether a customer or a competitor, to set out to damage the reputation of the business. This means reputation management is a boom area as supposed experts do their best to stem to tide of negative comments and restore the positive. For doctors, the problem is relatively new but growing in severity as sites like RateMD and DoctorBase now offer the chance for anonymous individuals to make their feelings known. Since people are most often motivated by poor experiences, the reviews tend to be negative.

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

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

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

The world is a complicated place to navigate safely. There are many ways the land and sea can play you false with quicksand to take you down and rip tides to carry you away from shore. But people are where the most serious problems begin. Some are naturally friendly and accepting of difference, while others will be hostile if you do not share their beliefs. Over the centuries, religion has always been a force to separate groups into different armed camps. It’s not much better today whether you look at the current strife between Christianity and Islam, or come down to the local level and look at the discrimination based on what people believe. In many ways, the idea of improved health care services should have united everyone but, unfortunately, aspects of the Affordable Care Act have been hijacked by interest groups and disapproval of the parts has been used to blacken the reputation of the whole.

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

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

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

So here’s a simple question for you as a fantasy decision-maker in charge of a state’s finances. Let’s say you go to court against Big Tobacco and come out with a big win. Because the court finally agreed to accept the medical evidence, Big Tobacco was ordered to pay money into a massive settlement fund. Every year, this pays out a big chunk of change to your state. What do you want to spend it on? It could be education except you really want to fire all the bad teachers first. Then you can use the extra money to pay higher salaries to attract better people into teaching and raise education standards. Ah, but that’s going to provoke a fight with the unions, so we’d better look for something less controversial. What about health? This would be ideal politics. The tobacco industry has made so many ill, it’s only right its money should be used to improve health care for all. Except how is that going to be done? Even a big lump of change gets lost in the total cost of running health care in a state. . .

Pennsylvania decided to use part of the money to fund adultBasic. This was an outreach plan for adults who would otherwise fall through the cracks. Their income is too great to qualify for Medicaid, but they can’t afford the premium rates for a private plan. The way it worked was simplicity itself. The state funded its own health plan. The actual cost per person was $600 per month, but the state only charged each person $36. The total cost of this plan in 2010 was $166 million. To give you an idea of the popularity of the plan, the state was subsidizing some 40,000 people with half-million people on the waiting list. Remember, there are some 50 million people without any form of insurance across the country. It should not surprise you there were so many people who felt they met the entry requirements for adultBasic in one state.

However, in February, the Pennsylvanian government announced it was looking at a big deficit, so Governor Tom Corbett looked around for cuts. Presumably feeling the 40,000 enrolled in the plan were freeloaders, he ordered the plan shut down immediately. Big Tobacco’s money now flows directly into the state’s coffers and is mixed in with general revenue. Curiously, the state has now discovered it will have a surplus of more than $750 million in the current year. It’s remarkable how quickly the fortunes of a state can turn around. One of the immediate consequences has been a 30% increase in the number of people walking into ERs around the state. This adds significantly to the cost of running the health care services. Ironically, this additional cost alone may be more than the state was spending on adultBasic.

The Democrats have been frustrated at their failure to get adultBasic reinstated. It was one of the few state-funded health insurance plans for the low-income group. Yet a Republican governor will always get political traction out of cutting such a high-profile example of “big government”. Adult Americans should pay for cover out of their own pockets and not look to the state to provide cheap health insurance (even with money from the tobacco industry).

More or less wherever you look, you will find the GOP propaganda machine churning out articles warning you that rationing is coming if the Affordable Care Act is fully implemented. The latest scare stories surround the entirely reasonable proposal to appoint an Independent Payment Advisory Board to recommend cost-saving changes to the reform program. This is a return to the death panel debate where a panel was going to sit to decide who should get treatment and who should be allowed to die. The GOP point to the British who have a panel called the National Institute for Health and Clinical Excellence (NICE) which often rejects expensive drugs, e.g. for the treatment of cancer including leukemia. In fact, NICE does quite often reject drugs, but only when there are cheaper alternates and there’s no evidence to show the more expensive drugs produce better results. Inevitably, some of these decisions are considered controversial by the British themselves but, so far, NICE has done a good job in keeping British healthcare service reasonably affordable to the taxpayers. For those of you who’ve forgotten, Britain has socialized medicine funded by the state.

Anyway, the GOP is convinced our new panel will decide the really ill, the elderly and the disabled will not be eligible to life-saving drugs and they will all be allowed to die. This will be rationing with intent to kill. All of which leads us to ask whether we have rationing now. As you may also have seen or read in the media, some 52 million Americans are without medical insurance. In simple terms, they cannot afford to buy a private health plan. So the current reality is that we have rationing today, but instead of it being based on patient need, it’s based on the patient’s ability to pay. Turning it around, those with the money in hand can afford to buy health cover. Everyone else either falls into a federal safety net or is left to fend for themselves.

As an example, let’s think about a young couple living together, both earning and producing just enough income to fall outside the Medicaid limits. They take no precautions and she now discovers her pregnancy. Instead of this being a time of joy, it’s a catastrophe. Assuming no complications, the pre-natal care and delivery usually costs about $20,000. With bad luck, this can double with some complications. It will cost her about $600 for an abortion. The comparison with Britain is instructive. If she lived there, both the birth or the abortion would cost her nothing. Whatever she chose would be free. Yes, their income tax as a couple would be higher but, averaged out over a lifetime of work, they would be better off. No matter what criteria you pick: access to care, the quality of care delivered, the efficiency of the services, the fairness of the decision-making and the general health of the nation, Britain comes out ahead of us.

So, given rationing already affects our health insurance services, survival depends either having the money to pay the premium rates or staying healthy. We would benefit from a universal system, but the GOP is determined to frustrate any move in that direction. Republicans believe our health insurance provision is not broken and needs no fixing.

Americans with concerns over their healthcare coverage are not being given much cause for optimism by Democrats or Republicans. While the Affordable Healthcare Act, which didn’t seem to please anybody, hangs in the balance of the debate, Republican candidates for president have elevated the rhetoric in their primary squabbles. Talk is cheap, but healthcare is certainly expensive. With this in mind, it is important to consider each candidate’s record of action on healthcare policy. Your own insurance could be at risk.

Michele Bachmann

In a very short national political career, Bachmann has been vocal about wanting no government involvement in healthcare. She is a leading voice in the attempt to repeal the Affordable Healthcare Act. In her rhetoric, Bachmann says that insurance and care will be better if left to market forces and that the government should not regulate it at all. Bachmann has actually backed up her words by voting against largely popular bills. She voted no to adding 2-4 million children to the SCHIP eligibility in January of 2007 and she voted against the extension of existing healthcare to 6 million children in January of 2008. In recent years, she has called for defunding all national healthcare plans, which would mean the death of Medicare and Medicaid.

She has claimed that the American system of healthcare is the finest system in the world. However, she has also called for fundamental changes to the American system by defunding existing institutions. According to all healthcare ranking world wide, the US is not number one, but somewhere between 37th and 49th.

Ron Paul

The Representative from Texas has been vocally against government involvement in healthcare, consistently voting against government spending and subsidizing healthcare. He has perhaps the most consistent voting record compared to rhetoric. He has called for abolishing Medicare, but has also protecting the benefits of people on Medicare. In 2011, he advocated allowing people to opt out of Medicare. In 2008, Congressman Paul said the country should replace Medicaid with “volunteer pro-bono medical care”. His own contribution to the discussion of a national solution to the healthcare crisis is to expand medical savings accounts.

Rick Perry

Governor Perry is openly in favor of free trade in healthcare and against any government involvement. He argues that this is the best way to promote responsible citizenship and to make healthcare coverage affordable. True to his word, Texas has not attempted to help the low-income and moderate-income families who are struggling and are without necessary medical care. Under his watch, Texas has seen its percentage of insured citizens fall dramatically, despite having higher employment and income numbers than most states, while seeing insurance profits skyrocket. He says he would end federal government involvement in healthcare if he is elected president, meaning millions more uninsured. If Texas is a measure, health insurance prospects would be bleak under President Perry.

Mitt Romney

The former Massachusetts governor was part of a massive health insurance reform that has made Massachusetts the best-insured state in the nation. He worked with state Democrats to provide mandatory care and health insurance vouchers for low-income and middle-income families. The results speak for themselves, but Romney has backed away from those successes, claiming he is pro-free market and anti-government regulation.

The recent tropical storm-cum-hurricane Irene ripped through North America, causing unprecedented damage in the Northeast. puts the importance of access to healthcare in perspective. While national debate rages on between Democrats, Republicans, and those more alienated from political power, many people have died or been beggared due to lack of care. A positive: Irene gives us new incite into the importance of, not only having insurance, but choosing an insurance provider with more than premiums in mind.

As GOP rally in South Carolina, hurricane spurs national healthcare debate.

Impact of Irene on Insurance

Whenever a natural disaster strikes, homeowners insurance and auto insurance claims see spikes. A reading of estimates from Kinetic Analysis Corporation, who specialize in predicting disaster effects, reveals that the storm cost insurers between $3 billion and $14 billion.

In New York alone, thousands of home and auto claims were filed the day after the storm. These large claims events have actually not changed premiums very much in the past. Insurers use data gathered over a long period of time. Since climate data is relatively consistent over time, as opposed to weather, tropical storms and hurricanes usually fall into the historic patterns and do not make a difference in insurance prices.

As climate change grows worse, however, all bets are off. The increased frequency and ferocity of hurricanes is an example of the impact of climate change. Climate then becomes less reliable a factor for insurers. If climate does change for the worse, as even NASA agrees, people will be more vulnerable and insurance costs will increase.

How Healthcare Coverage Differs

Medical coverage works a bit differently. The statistical risk of people getting injured by or needing more care as a result of natural disasters depends less on natural disasters and more on affluence. When a hurricane of the same force hits Haiti, it does far more damage than when it hits New York. Likewise, when a hurricane hits the United States in a time of economic strength, the human cost is likely to be less than at a time of economic weakness. This is confirmed when you see the casualties and monetary damage from disasters in the Clinton years and compare them to those from the Bush and Obama years.

Without the millions more who had been insured under the Affordable Care Act, the damage might have been even worse. The homeless and the poor are always hit the worst by hurricanes – people who are more vulnerable to storms and, due to a lack of insurance, are unable to get treatment and rebuild afterward.

For those who can still afford health insurance, it becomes essential to pick the right provider. Case in point: CIGNA insurance company. While most health insurance providers were panicking over the increased costs to them from Hurricane Irene, CIGNA extended a helping hand to its policyholders.

It lifted restrictions over which places customers could go to for medical procedures and medications. If someone had lost a refill or had prescriptions damaged, CIGNA offered to let them get their next refill early with full coverage. If they needed urgent care, they need not worry about which professional they went to, since CIGNA offered in-network benefits for any urgent care facility and any hospital admission.

Choose your health insurance provider carefully

Over the last few months, there’s been a really vicious political fight over the deficit. The Tea Party has fired up the Republican party into a hardline stance on reducing the amount we owe as a nation. The strategy has been direct and effective. The GOP has said “no” to any government plan that tries to raise taxes. So many members have signed the tax pledge written by Grover Norquist. This closes debate on the matter for them. There can be no compromise. The effect of this is dramatic. With the same amount of money coming into the federal coffers, it must cover the essential services and everything else is to be shut down through lack of funds. One of the more obvious issues is healthcare.

As a result of the Affordable Care Act, about 21 million people will gain access to insurance. It’s true this will put a serious strain on the primary care services. Indeed, when you look at the shortage of doctors prepared to work in the primary care sector today, the idea the existing physicians can absorb all these extra patients is daunting. The doctors are struggling now. Come 2014 when all the extra patients will become eligible for cover, the bad situation will become worse. Independent groups have been trying to estimate the costs of this, but it’s difficult because of the culture in the medical profession. Too many doctors see primary healthcare as second-best. The status and prestige is attached to working in a hospital. So just increasing the pay for doctors in the primary sector is not going to change attitudes. Whatever happens, there will be a shortage of doctors come 2014.

But this is nothing compared to the problem of the aging Boomers. An increasing percentage of the population is going to pass into retirement. There’s an inevitable consequence to the aging process. The body starts to slow down. Parts break. People get injured or fall ill more often. There’s already a sign of an increase in the number of older people seeking treatment for a wide range of age-related problems. Some estimate that outpatient visits to hospitals and clinics will rise even more sharply as more Boomers pass the age of 65. This has major implications for Medicaid and Medicare funding. Under normal circumstances, we could view all this with a calm and detached mind. The politicians have always managed to find the funding for those dependent on the healthcare services. But with the deficit debate firing up the GOP, it may be difficult for the Democrats to maintain full funding for all the medical entitlement programs. Put simply, if the GOP blocks tax increases, what will Washington cut to save healthcare funding?

No matter whether the Supreme Court rules Obamacare constitutional, there’s one certain fact. Unless something is done to control the costs of healthcare services, cheap health insurance will be a thing of the past. Premiums must rise to match the high prices for drugs and the treatments delivered by hospitals and clinics. Even if the mandate survives and more money is paid as premiums by the new policyholders, there will still be a shortfall. So something needs to change in Washington to build a consensus on how to keep health insurance rates affordable over the next five years.