Hi. My name is James Walsh. The producers of this site have asked me to write a twice-monthly column on health insurance topics for consumers. This is the first of what I hope will be many useful takes on the current state of health coverage in the United States.

A few quick notes about my qualifications. For the last decade, I have been the editorial director and publisher of the Merritt Manuals, a multi-volume technical reference encyclopedia used by insurance companies, risk managers, agent/brokers and claims adjusters. The Insurance Training Collection, an educational tool based on the Merritt Manuals, helps agents throughout the United States get and keep their licenses. I’ve also written or edited consumer books on risk and insurance, including the bestsellers True Odds: How Risk Affects Your Everyday Life and Get Your Claim Paid.

But enough about me. The purpose of this column is to give you, the reader, two things:

1)    a working understanding of how health insurance policies work and the health insurance marketplace operates; and

2)    practical tips for buying the best coverage for the best price.

This column won’t promote certain companies or products; I’ll focus instead on information that will help you make the best health insurance buying decisions for yourself and your circumstances.

You know your health insurance needs better than anyone, better even than experts and professionals. The first step in buying the right coverage is to focus attention on your situation and needs. To that end, here are seven basic tips that you should keep in mind when shopping for health insurance:

1)    Know yourself and your family. This simple point is important because who you are—including your age, gender and health history—is the most important factor when it comes to setting up and pricing health insurance coverage. And “you” is not always a single pronoun; a couple has different needs than a single person…who has different needs than a family with young children.

2)    If you have a family, getting health insurance coverage for some members may be easier than for others. While it’s easiest to insure everyone under a single policy, it might be more effective to insure kids under one policy, adults under another or individuals with specific health issues separately. This requires organization on your part—but can yield better results, in terms of cost, coverage and claims paid.

3)    Know your own health history and the histories of everyone in your family. Surprisingly, some people prefer “not to know” about their overall health—especially if they have family histories of conditions like high blood pressure, cancer or genetic diseases. But this kind of “ignorance is bliss” outlook doesn’t work well for anyone in today’s world.

4)    Understand that insurance policies are contracts between you (sometimes called “the insured”) and an insurance company (sometimes called “the carrier). Most terms and conditions can be negotiated, if you are informed and determined. Finding a good independent insurance agent can help this process. A lot.

5)    Some people in the health insurance field hide behind legal jargon and tell consumers this or that request is “illegal” or “against the law.” Most insurance-related laws and regulations (leaving aside the Affordable Care Act of 2010) put requirements on insurance companies, not insurance consumers. There’s not much—short of outright fraud—that an insurance consumer can do that’s against the law. In most cases, the main risk that an aggressive consumer faces is that his or her policy gets cancelled or rescinded at some later date.

6)    Insurance, by industry tradition and design, is difficult to shop for on a comparison basis. Health policies and contracts are structured in such a way that “apples to apples” comparisons are difficult; but you can make effective comparisons by learning some essential jargon and knowing standard policy components.

7)    The health insurance marketplace is going through more radical change than at any time in the last 50 years. In many cases, even experienced professionals aren’t sure what current laws or regulations require…or what current market conditions mean for specific types of coverage. This can make some professionals (whether they work for insurance companies, broker/agents or government regulators) nervous and defensive. But the good ones will admit that industry standards are changing fast—and will work with you to answer questions or find solutions.

Clearly, the Affordable Care Act of 2010 (known in many circles as “Obamacare”) has affected—and will continue to affect, even if it’s modified or repealed—the market for health insurance coverage in the U.S. So, this column will look at that law often and from various angles. But I’m not interested in partisan politics or repeating talking points from political party or another…or one trade association or another. My only interest is in analyzing the law and related regulations for how they will affect how you buy health coverage.

There’s an old saying in the insurance industry: The best kind of insurance is the one that pays when you need it. My main goal in this column will be to help you get that kind of health coverage.

More specifically, in the coming weeks and months, this column will consider the following topics:

• getting health coverage for children and “young adults”
• how health insurance rates are regulated—and how quickly the premiums you pay can rise
• how you can measure the financial strength of an insurance company—using credit ratings and statistics like medical loss ratios, etc.
• what to do if you are turned down for health coverage by a private carrier or government program
• how standard health insurance pays for preventive care, alternative care and other non-standard therapies
• what you can do if/when your health insurance coverage is cancelled
• what you can do if your insurance doesn’t cover a specific treatment or type of care—or decides a treatment is “experimental,” etc.
• how “Obamacare” compares with “Romneycare” and other earlier versions of health insurance reform
• how to compare group health plans with individual health plans
• using and dealing with Medicare and Medicaid
• what happened to the popularity of HMOs, PPOs and other types of “managed care”
• whether Health Savings Plans or other non-traditional programs will work for you
• how hospitals and doctors consider various types of insurance coverage
• the role that cash plays in the marketing of medical care

Putting together these articles, I will be assisted by a team of researchers and writers with great experience in health insurance and health coverage issues. This team includes:

• Sheldon Lipshutz, M.D., author of the book 10 Things You Need to Know Before Your See the Doctor and a physician with more than 50 years of experience;
• Gus Herrera, a co-author and contributor to such books as Hassle-Free Health Coverage and Kids and Health Care;
• Callie Branaugh, an assistant editor/researcher for the Merritt Manuals (and daughter of the novelist Seamus Branaugh) who has also contributed to consumer insurance books such as Family Money and the Insurance Buying Guide.

Let me end this first column with a quick story.

About two years ago, a young woman called my office asking to speak with me about one of our consumer insurance books. I was worried it might be a complaint about some fact or opinion in the book—but it was a thank-you call. The woman was a single mother who’d bought a copy of Kids and Health Care. The book had helped her get her kids insured under a state-run program. She told me: “I knew there was information on the Internet about getting them insurance. But I didn’t know where to start. I mean, this stuff is intimidating. Your book explained it well enough that I felt like I could ask the right questions.”

This column will try to make this stuff less intimidating.