The High Cost of Health Insurance: Talk v. Action

My background is research. Inquiring minds really do want to know, and with a few phone calls and quality time on the Internet, you can find out a lot.

In my work, I’ve run into three types of people:

  • Those who charge high prices for health insurance
  • Those who complain about the high prices for health insurance
  • Those who do something about it

Yes, really, the third category exists. Apart from the Marketplace, I know of at least two good ways to cut costs dramatically without skimping on coverage. These are solutions provided by established organizations, not something I’ve cooked up. However, most people don’t know about them.

Best of all, they don’t involve any political uncertainty. “Trump” is not part of the vocabulary for these solutions.

I’m not going to explain them here, because I might run afoul of regulators saying that I’m providing insurance advice in a state in which I haven’t paid for a license yet.  (I’m licensed in NJ, PA, MO and VA.) If I don’t handle your area, I will still tell you what the solutions are and provide a referral to someone who can help you.

So if you want more information, you’re going to have to call or email me.

609-510-3712

vic@craininsurancellc.com

This is my way of trying to be useful.

Vic Crain

Anyone want to move to Hawaii?

United Benefit Advisors has produced this chart showing group health insurance costs by state.

It should come as no surprise that the Northeastern US is the most expensive area of the country for group health insurance.  However, the amount of difference in cost might be a shock.

These are 2016 figures.  The numbers for 2017 are a little  higher, and we expect the numbers for 2018 to increase by more than 15%.  These are costs under group heath insurance policies.  The cost for individual policies will be slightly higher (before the ACA subsidy is applied).

2016 Monthly Premium by state Chart.jpg

The Economy: Back to the Future

Have you heard the advertising mantra, “Perception is reality”? It’s not. Reality is based on data that isn’t subject to twisting by political pundits — for example, a rapid growth in inventory of unsold cars and trucks at US dealers. The election brought about a rally in consumer confidence and in the stock market without […]

via The Economy: Back to the Future — CRAIN’S COMMENTS

Trump’s Actions on Healthcare to Date

Medscape offered a good review of Trump’s initial executive orders regarding healthcare.  ben_franklinI’m not going to repeat the article word-for-word here — just recap the basic points and what they might mean for you:

  • They are largely non-specific recommendations, leaving actual implementation to each agency.  Since most of the new Cabinet heads aren’t confirmed as yet, this is going to play out over time.
  • The executive order could end penalties for not having health insurance.  That sounds good until you realize that it will drive up the cost of health insurance for everyone else.  The notion of risk pool is that healthy people balance out the ill.  If you allow people who don’t use much health services to withdraw from the pool, the cost burden is born by the smaller number of people remaining.  It’s simple math.
    • On notion starting to be discussed is the idea of a “high risk” insurance pool for people with chronic health conditions.  This was tried in a number of states in the past for both health and auto insurance and failed in both areas.  States discovered that they were on the hook for budget-breaking sums and the cost to individuals soared.  (See Politz article, in sources, below.)
  • States will be given greater latitude to determine who qualifies for Medicare and CHIP assistance and what assistance these programs actually provide.  That’s OK if you live in the Northeast or West Coast, and not so good elsewhere.
  • Health insurance will be sold across state lines.  That’s a questionable benefit:
    • It reduces the power of state insurance commissioners, which could be a good thing.
    • The impact on the actual cost of insurance is questionable.  Take New Jersey, for example.  Residents will have more policy choices available, but those policies now sold in Pennsylvania and New York have higher prices than New Jersey allows.  It seems unlikely that a carrier that sells in both NJ and PA will bring a lower priced policy from NJ to consumers in PA.
  • It will repeal taxes imposed on pharmaceutical companies and insurance carriers.

Bottom line:  The initial actions favor insurers and pharmaceutical companies at the expense of consumers. Health insurance prices will increase this year.  The Congressional Budget Office estimated that Trump’s actions would double the cost of health insurance over the next 10 years.  That may be an underestimate.

However, I don’t suggest running out to buy stock in these companies.  The theme over the last decade is that draining consumer wallets is a good way to bring the economy to a halt and, eventually, crash the stock markets.  It’s been done before.

It’s time to cut your expenses and save as much as you can.


Sources:

ACA Reform: the newest wrinkle

OK, it’s widely understood that “ethical Congressman” is an oxymoron if not an entirely extinct species.

Georgia Representative Tom Price is a Congressman.  He also invests iskunksn medical technology and pharmaceutical companies to the tune of about $300,000.  He also introduces bills and writes letters to regulators to help the companies whose stock he owns — boosting the value of  his own investment.   In turn, the companies donate to his re-election campaigns. (The Wall Street Journal first broke this story in December; CNN added new information today.)

Basically Tom Price is a poster child for “conflict-of-interest.”  Government is supposed to be “for the people”, not for your own wallet.

Price is also Trumps nominee for Health and Human Services Secretary and Trump’s designated leader on ACA reform.

If he’s leading the charge, just who is the real beneficiary of ACA reform going to be? 

In fairness, Price says that if he gets this new job, he will get rid of all of his stocks within 90 days.  However, he’s been in Congress for 11 years, with a consistent pattern of behavior.  That’s going to change overnight?? Plus ACA repeal reportedly will occur before he has liquidated his stocks, if it happens as promised.

Of course, the voters of Georgia share the blame for this mess. You elected someone five times who has consistently violated ethics rules.  How exactly does that work?   

Price’s original proposals for ACA repeal included the following five elements (quoted from NPR article cited below):

  1. Price’s plan offers fixed tax credits so people can buy their own insurance on the private market. The credit starts at $1,200 a year and rises with age, but isn’t adjusted for income. Everyone receives the same credit whether they are rich or poor. People on Medicaid, Medicare, the military health plan known as Tricare, or the Veterans Affairs’ health plan could opt instead for the tax credit to buy private insurance.
  2. Price advocates for expansion of health savings accounts, which allow people to save money before taxes to pay for health care. This includes allowing people who are covered by government health programs including Medicare and the VA to contribute to health savings accounts to pay for premiums and copayments. These proposals are included in Ryan’s plan.
  3. People with existing medical conditions couldn’t be denied coverage under Price’s plan as long as they had continuous insurance for 18 months prior to selecting a new policy. If they didn’t, then they could be denied coverage for that condition for up to 18 months after buying a new plan.
  4. The Price proposal limits the amount of money companies can deduct from their taxes for employee health insurance expenses. Companies can deduct up to $20,000 for a family health insurance plan and $8,000 for an individual. The goal is to discourage companies from offering overly generous insurance benefits to their workers. Ryan’s plan proposes a cap on the employer tax deduction but doesn’t specify the level of the cap.
  5. States would get federal money to create so-called high-risk pools under Price’s plan. These are government-run health plans for people with existing medical conditions who can’t get affordable health insurance on the private market. Critics say high-risk pools have been tried in as many as 34 states and largely failed because they were routinely underfunded.

Given that a Silver level ACA plan in NJ can cost upwards of $900 per month, a $1,200 annual credit doesn’t amount to much. And why should the credit be the same for a millionaire as for someone making minimum wage?  The pre-existing condition rule means that some people with long term health issues will be excluded from coverage. 

Finally, do Price’s ethics issues have anything to do with GOP efforts earlier this month to reduce or eliminate the independent Congressional Ethics Office? 

The Affordable Care Act (aka Obamacare) repeal is turning into a circus.  I’m sure there are more acts to follow.


Sources:

  • http://www.cnn.com/2017/01/16/politics/tom-price-bill-aiding-company/index.html
  • http://www.npr.org/sections/health-shots/2016/11/29/503720671/5-things-to-know-about-rep-tom-prices-health-care-ideas
  • http://ktla.com/2017/01/16/trumps-hhs-nominee-introduced-legislation-to-help-company-soon-after-investing-in-it-house-records/
  • http://www.msnbc.com/rachel-maddow/watch/ethics-questions-loom-over-trump-hhs-pick-rep-tom-price-839983683992
  • http://www.wsj.com/articles/donald-trumps-pick-for-health-secretary-traded-medical-stocks-while-in-house-1482451061

Healthcare: what you do need to do now

Donald Trump promised today that there will be “healthcare for everyone” after repeal of the ACA. He can actually do that very easily and cheaply, by cutting back the healthcare provided to “catastrophic” coverage. This category of plan exists today, but almost no one actively sells it because if provides very little value to the […]

via Healthcare: what you do need to do — CRAIN’S COMMENTS

ACA Reform

If you have insurance coverage through the Marketplace, the key advice right now is —

DON’T PANIC.logo@2x.png

While, to paraphrase Mark Twain, the word “congressman” is a synonym for “idiot”, it’s unlikely that we’ll see sweeping changes in the near future.

  • Congress is using a special procedure to “repeal” the Affordable Care Act (also known as Obamacare).  In fact, using that procedure, they can only repeal a portion of the law — the portion that involved direct Federal spending and tax penalties for individuals and businesses.
  • Many smaller hospitals are just as upset as consumes about losing Federal subsidies for healthcare.  The can’t afford returning to the burden of treating the uninsured.  Since the medical community is such a huge donor to Congress, they will want their say in hearings before Congress acts. So will insurers, the AARP and other groups.  That takes time.
  • Several analysts have speculated that there will be some kind of “bridge” legislation to keep the current system running until they can come up with a revised system.  That would be sensible.  But then again, this is Congress.

The bottom line is that we need to know what the facts are before we can figure out what is best to do.  Until the dust settles, we just don’t know.

Any replacement system will require legislation that will be subject to filibuster.  For that reason, it will require support from both parties to put it in place.  That’s simply going to take time.  I’d be modestly surprised if we actually had a replacement system before 2018, and if passed then, it wouldn’t take effect until 2019.  But we’ll see.

However, panic over the law could trigger a pull back in spending by consumers.  Another recession?  We’ll see.

By the way, if you haven’t read Mark Twain — particularly his cynical “Letters from the Earth” — you really should.  Most of what he said about people and  especially politicians is still true.  He’s just a lot more humorous in how he says it.

 

Older Men and the Women Who Love Them, More — CRAIN’S COMMENTS

Cleaning out my mailbox, there was an article on this in Science Daily from earlier this year that’s important for older men and the women who love them to know. Low testosterone levels complicate recovery from hospital stays, according to a study from the University of Texas. Testosterone levels fall in men after age 40 […]

via Older Men and the Women Who Love Them, More — CRAIN’S COMMENTS

Insurance for the disabled

This is a subject I’m working on now.

Insurers have no problem writing life and disability policies for healththlx3t6c8yy people.

However, getting insurance for someone who starts as disabled (e.g., autism, brain injury) is a challenge.  Certain states make that even more difficult.  For example (thank you Governor Christie), it’s illegal in NJ to write certain types of insurance for people on Medicaid.  If you’re poor, the state makes it harder to dig yourself out.

thzaeabdiqHowever, there are solutions.  As an agent, I have to dig to find them.  Most consumers wouldn’t know where to look.

Happily, I’ve always enjoyed doing research.  It’s my calling.

By the way, there are people who invest in life insurance at age 18, before there’s an opportunity for much to happen to them.  They’re smarter than I was.  If healthy, they have more options and policies are very low cost.

This is an insurance/health focused blog.  I have a related blog at “Crain’s Comments” (vlcrain17.wordpress.com) that addresses a range of additional topics in writing, finance, technology, science and medicine. 

Insurance: Please don’t buy this!

135354-RumorsJust because someone offers a product, that’s no reason to buy it.  Some just don’t make sense, except perhaps in an alternative universe.

The newest entrant in this category is something called “Active Shooter” insurance.  These policies first appeared on the market in 2015 and are designed for business owners.

Now let’s think about this.  The US averages 51 deaths due to lightning strikes per year (source: NOAA).  It’s probably fair to assume that this averages one death per lightning event.  The most common activity among victims when hit by lightning was fishing.

Now, between 2000 and 2013, there were an average of 11.4 mass shooting events in the US each year (source FBI).  This number has risen recently, of course.  The FBI reports 20 such incidents in each of 2014 and 2015.  The number of people killed per event is greater than in the case of lightning strikes, but still, there were only 20 of these.  There were 20.9 million business in the US as of 2010 (Census), so the odds of a business incurring an active shooter event is 0.0000095694%.

The business has a much better chance of being hit by lightning.  How many businesses have lightning rods?

By the way, if you believe in Apocalypse theory, most insurance policies exclude claims due to “acts of war.”  Earlier this week, commentators on Fox endorsed the US “declaring war” on ISIS.  That recommendation would elevate ISIS to the status of a country AND eliminate some insurance protections Americans do have.  That’s why you don’t listen to Fox.

Anyway, Active Shooter insurance seems to me to be a silly way for the paranoid to waste money.  If you have money to waste, I can think of lots of better ways.

Health Insurance: the Uniquely American Jungle

VCphoto2To paraphrase a quote from a friend, it doesn’t matter who helps you with insurance until it does.

There’s no single policy or company that provides “complete” health insurance in the US.  Truly complete coverage involves stitching together policies from multiple sources while keeping costs manageable.  It’s the insurance version of quilting.

Your daughter breaks her arm playing basketball at school.  The doctor’s bill is $1200.  How are you paying for it?

You’re overdue for a colonoscopy.  Do you know that the cost can vary wildly depending on where it is done?  Will you be out of pocket for this or will your insurance cover the cost?  Do you know?

In medicine, it is the case that “an ounce of prevention is worth a pound of cure.”  Catching any illness in the early stages of development makes it easier and less costly to treat.  Most Stage I cancers are easily treatable at little cost; most Stage IV cancers are fatal and very expensive to treat.

For consumers, this means that annual check-ups aren’t optional.  doctor-clip-art-doctor-clip-art-4Nor are mammograms, colonoscopies or esophageal endoscopies.   By the time you become aware of a blockage of the esophagus (without a screening), it’s Stage IV and your five-year survival rate is less than 10%.  You’re basically done.

The problem for consumers is being able to pay for check-ups and screenings.  That’s where the fine print in your health insurance becomes critically important.  Some policies will cover screenings and some don’t.  If your policy doesn’t, and you have a high deductible, you could be liable for thousands of dollars in costs.

As the New York Times reported (10/17/2014 and 11/15/2015), there are consumers who have health insurance and still can’t afford to see the doctor.  They can’t pay the deductibles and co-payments, so the simple act of buying insurance becomes largely irrelevant.  The Affordable Care Act (aka ACA or Obamacare) simply didn’t go far enough to solve the problem of affordability.  A lot of that is related to accommodations required to overcome resistance to passing the law.

There are some resources, although some in Congress and the states are trying to cut the budget for them.  Planned Parenthood provides mammography for poorer women, but has become a target for other services in which it is involved.  There are also public health clinics, but these are only in limited locations.

Ultimately, the consumer is faced with an array of options and costs:

  • Private insurance, Marketplace insurance, Company-sponsored insurance or no insurance
  • Low or high deductibles
  • Low or high co-payments
  • Whether to include options such as dental, vision or supplemental health insurance
  • Choice of insurance company
  • Choice of doctor and hospital
  • Whether insurance covers travel out-of-state (some plans don’t)

Even seniors have to make choices between Medicare, Medicare Advantage and Medicare supplement plans.  Nothing is simple anymore.

Very few people can afford the high-end plans that cover everything with next to nothing out of pocket.  Even in the Marketplace, such plans can cost upwards of $2,000 per month, which is more than a  lot of people make in a year.  That’s higher than most mortgages.

That brings us back to the question of who advises you about health insurance.

  • Most agents are sales reps, trained to sell a particular policy and not necessarily familiar with the options that consumers may have.
  • With substantial turnover among agents, a lot of agents you meet will have been in the business for less than a year.  Some of these will make mistakes in presenting what their own policies do and don’t do.  That’s not a criticism.  Think about it: that’s why there are learner’s permits for drivers.
  • Under a new and controversial rule, investment advisors are required to place the well-being of the consumer ahead of the advisor’s financial interest.  There is no similar requirement for health insurance agents, although there should be.

So you can either hit the books and become an expert in health insurance yourself, or find someone who is.

There are agents with experience, knowledge, and who place the well-being of the consumer first.  We’re not perfect, but if we don’t know something, we tell you and then we do research and find the answer for you.  We don’t rush you into purchase decisions, but when we work together, we design a plan or set of complimentary plans that will take care of what you, your family and your employees need within your budget.

We’re here to help you complete your insurance quilt.

Vic Crain
Partner
Crain Insurance
vic@craininsurancellc.com
609 510-3712

Microcephaly and Politicians

Zika has hit the US.  According to the CDC, there are now 279 pregnant women on US soil with Zika (3).  That number is likely to skyrocket this summer.  Mosquitoes will bite infected women and spread the disease to others.  Others will visit infected areas, especially with the Brazilzika2.png Olympics this summer, and return with the disease.  Sexual activity may spread the disease.

Meanwhile, the Oklahoma legislature creates a bill that removes any discretion in bringing infected babies to term.

Regardless of the intent in becoming pregnant, no one intends to bring a baby to term who will live for only 4-5 years and cost a fortune in terms of heartache and cash.  That’s not why someone becomes pregnant.

Women understand this.  The Zika outbreak is increasing demand for abortions in the countries that have been affected seriously thus far. (6)

However, because there is no lethal risk to the mother, under the Oklahoma law, a woman has no choice in bringing the baby to term.  The state will incur a mountain of costs in caring for these children, as most families cannot bear the load.

Even the Pope has expressed openness to the use of artificial contraception to deal with Zika.  (2)

Arguably, having a functioning brain should be a requirement for public office.

American writers have been quick to criticize Brazilian politicians for a slow response to the Zika outbreak.  However, as with the Michigan water crisis, this is evidence that American politicians can be just as oblivious.  The US Congress has been no better than Brazil’s in taking preventive action. (1)  The US is quite unprepared for the expected medical costs Zika will create. (5)

What actions can you take?

(a)  Adjust vacation plans.  The mosquito that carries Zika is prevalent in the US south, especially in the Gulf Coast region.

(b) Wear mosquito repellant.

(c)  If you or someone about which you care is pregnant, make sure they have access to good prenatal care and use it.  This is not a surprise you want.

(d) More controversially, lobby your local government for mosquito control measures.  That can affect other wildlife, but that may be a necessary sacrifice until this is past.  Hopefully, Zika won’t become a permanent part of our ecosystem.


Sources:

(1) Branswell, Helen.  “Congress is blocking key efforts to fight Zika, top health officials say,”  STAT News, 10 March 2016.  https://www.statnews.com/2016/03/10/zika-emergency-funding-anxiety/

(2) Burke, Dan and Cohen, Elizabeth. “Pope suggests contraceptives could be used to slow spread of Zika,” CNN.com, 16 February 2016.  http://www.cnn.com/2016/02/18/health/zika-pope-francis-contraceptives/index.html

(3) Cohen, Elizabeth.  “Number of pregnant women with Zika virus in U.S. triples, CDC says.”  CNN.  10:21 AM ET, Fri May 20, 2016.  http://www.cnn.com/2016/05/20/health/zika-cdc-numbers/index.html

(4)  “Oklahoma lawmakers OK bill criminalizing performing abortion.”  Associated Press. 19 May 2016.  http://www.msn.com/en-us/news/us/oklahoma-lawmakers-ok-bill-criminalizing-performing-abortion/ar-BBtfoqO?ocid=ansmsnnews11

(5) “Public Health Experts Warn U.S. Unprepared for Zika Outbreak,”  Insurance Journal, 13 April 2016.  http://www.insurancejournal.com/news/national/2016/04/13/404972.htm

(6) Simmons, Ann.  “Zika fears increase demand for abortions in countries where it’s illegal to have one,”  Los Angeles Times,  9 March 2016.

 

New Reasons Why You Need a Second Opinion

Ownership interest in dealers of medical devices can encourage doctors to recommend surgeries that are not medically necessary.

Most consumers view their doctor as a professional who will treat their illness in an objective and unbiased manner.  Unfortunately, some doctors have conflicts of interest of which their patients may be unaware.

doctor-clip-art-doctor-clip-art-4

The Wall Street Journal reports a new study that shows that  some doctors invest in dealers or distributors of medical devices used in surgery.  The doctor profits on sales of surgical products.  The profit motive may cause the doctor to refer patients for surgery more often than is medically necessary.(1)

The idea of medical conflict of interest isn’t new, but has traditionally focused on the relationship between doctors and drug companies.  The American Medical Association set for guidelines for doctors to follow regarding conflicts in 2009.(2)  However, there is no measure of how well doctors are following those rules.

A “conflict of interest” is a situation in which  someone who has to make a decision in an official capacity stands to profit personally from the decision”.(3)  Regardless of legality, anyone who makes a  decision when there is a conflict of interest is acting in an unethical fashion.  Judges are expected to recuse themselves (reassign a case to a different judge) when a conflict arises.  Ethically, that’s what every public official or business executive should do.  In practice, most don’t.

At the very least, officials should disclose possible conflicts and let the consumer or patient decide how to deal with them.  Licensed financial advisors are required to do this.  Others should be, but are not.

You don’t want your health to be compromised by a conflict of interest.  Even a successful surgery can have a lasting impact on your quality of life.  That means getting a second opinion on a diagnosis and recommended course of treatment, preferably from someone in an entirely separate medical practice.  If the doctors disagree, you may need a third opinion.

If your doc has a conflict of interest and doesn’t  disclose it to you, you need a new doc.  Integrity matters.


Sources:

(1)  Armour, Stephanie.  “Doctor-Device Deals Need Scrutiny, Report Says,”  The Wall Street Journal.  May 10, 2016.  P. A3.  (Yes, some of us still use printed versions of newspapers.)

(2) Institute on Medicine as a Profession.  “Conflict of Interest Overview”. http://imapny.org/conflicts-of-interest/conflicts-of-interest-overview/

American Medical Association, “American Medical Association Conflict of Interest Principles – Councils, Committees, and Task Forces.”  http://www.ama-assn.org/ama/pub/about-ama/our-people/ama-councils/conflict-interest-principles.page?

(3) http://www.dictionary.com/browse/conflict-of-interest

Sanity, Finances and Supplemental Insurance

Realistic thinking and an ounce of prevention can give you a happier life.  If it sounds simple, it actually is.  It’s harder to change one’s mindset than it is to take the actions that are needed.

Most Americans, and certainly older ones like me, grew up with several assumptions about how our lives would play out.

(1)  Income will increase over time.  Taking on debt now is OK, because you can pay it off with increased earnings in the future.

(2) Housing is an investment.  The value of housing will increase.  Buy as  much as you can afford now, and make money when you sell.  Take on an equity loan now, and the growth in value will enable you to sell, cover the loan and still make a profit.

(3) Kids will do better financially than their parents.  In  your old age, your kids will be able to help you if needed.

(4)  Social Security is there to cover basic expenses in retirement.

(5)  You will be able to retire and enjoy yourself in your later years.

Like the Easter Bunny, these are wonderful myths.  However, trying to live as if they were true is a quick path to what some analysts call, “money depression.”(1)  That in turn is linked to problems with relationships and health.(2)

That’s the deadly spiral:  money problems can trigger depression, which can trigger health problems, which can add to money problems.

The blind faith in the future is what enables people to spend everything they earn and dive into debt.  It’s why almost half of Americans admit they would have trouble handling even minor financial emergencies, like a $400 medical bill.(3)

The new era of “living within one’s means” requires three things:

(A) Realism about the lifestyle one can afford

(B) A realistic budget

(C) Resources to deal with “the inevitable unexpected”, so that these don’t siphon off money you need for other things.

Item (C) is where supplemental insurance fits.  No one expects to get sick or have an accident, but the average American spends over 9 years of his/her life dealing with illness or injury.(4)  No one expects to have an accident.  Most cancers in the US are now attributed to environmental rather than genetic factors.(5)  You simply cannot plan on staying well.  That’s not something you fully control.

Supplemental insurance works by providing cash to those who are hurt or ill.  The cash is paid to the insured rather than to healthcare providers, and can be used to meet health insurance deductibles and copays, as well as to pay living expenses while ill.

Supplemental insurance makes sense for most people because it is very low cost.  Policies start at less than $20 per month for individuals, and less than $40 per month for families.

Financial peace of mind means having a budget that works and knowing that you are protected to the extent possible against the “inevitable unexpected.”  Once you achieve financial peace of mind, you’ll find you have the time and energy to tackle other challenges in your life.

 


Sources:

(1) Williams, Goeff.  “7 Steps to Defeat Money Depression.”  US News.  6 Aug 2014.
Harding, Anne.  “When Money Ruins Your Mood.”  Health.com.  http://www.health.com/health/gallery/0,,20541338,00.html

(2) Crown, WH, et. al.  “The impact of treatment-resistant depression on healthcare utilization and costs. The Journal of Clinical Psychiatry

(3) Gabler, Neal.  “My Secret Shame.”  The Atlantic Monthly [may 22016: 52-63]

(4) The World Health Organization gives the health life expectancy for US citizens as 69 years, as compared to a current life expectancy of 78 years.

(5) http://www.cancer.gov/about-cancer/causes-prevention/risk/substances
http://www.cancer.org/cancer/cancercauses/