Here are snapshots of seven Americans:

___

Name: Michael Esch

Home: Warwick, N.Y.

Age: 48

Occupation: Former middle manager for medical device company, now working as a hospital purchasing agent.

Insurance coverage: Paying out of his own pocket for COBRA insurance through his former company.

Esch, a father of three, lost his job in November in a layoff his employer said resulted from President Barack Obama’s health care law. Medical device maker Stryker Corp. announced in November it intended to lay off 1,000 workers worldwide to save money ahead of a 2.3 percent tax on medical devices that starts in 2013.

The tax on medical devices is meant to help pay for expanding health coverage to uninsured Americans. The Obama administration argues device companies will gain in the long run as more patients become eligible to receive their products because they have insurance.

Esch was a middle manager who had worked for Stryker for six years. He helped develop a product known as the Triathlon Knee. Since the layoff, he’s taken a salary cut to work as a hospital purchasing agent. He’s still looking for a job with another medical device company.

He blames the medical device tax for the loss of his job, but he’s grateful for the provision in the health care law that will allow his oldest child, now a college sophomore, to stay on his health insurance to age 26.

“We tend to forget that for every great idea there is a ripple effect through other sectors of a business,” Esch said.

Economists say most companies should be able to pass on the bulk of the tax to customers, but the industry says it will squeeze profits and chill investment, hiring and innovation.

___

Name: Glenn Nishimura

Home: Little Rock, Ark.

Age: 62

Occupation: Consultant to nonprofit groups.

Insurance coverage: Uninsured since COBRA coverage from a previous job expired in May of 2009.

Nishimura has been uninsured for nearly three years. He lost his health coverage after he left a full-time position with benefits in 2007, thinking he could land another good job. The recession destroyed that plan.

He’s been denied coverage because of high blood pressure and high blood-sugar levels. A provision in the national health care law gave his state $46 million to insure people like him who’ve been denied coverage because of pre-existing conditions.

But Nishimura said he can’t afford the coverage. It would cost him about $6,300 a year in premiums with a $1,000 deductible, meaning he would pay the first $1,000 out of his own pocket before coverage kicks in.

He worries about suffering injuries in a car accident or falling ill before he’s eligible for Medicare at age 65.

“I don’t like feeling vulnerable like this,” Nishimura said. “I’m completely vulnerable to some catastrophic problem.”

Nationally, about 50,000 people with pre-existing conditions have signed up for the coverage available through the health care law, fewer than expected. The government has offered new options to encourage more to enroll. In another two years, he may be eligible for subsidies under the law for insurance.

___

Name: Samantha Ames

Home: Washington, D.C.

Age: 25

Occupation: Law student

Insurance coverage: Got back on parents’ insurance, thanks to the health care law.

As a teenager, Ames was prone to ankle injuries playing catcher on baseball and softball teams. Last April, she tripped over her mini bulldog and badly injured her left ankle. Ultimately she needed surgery that cost her insurer $30,000.

But she considers herself lucky.

Only a few months before her accident, Ames had been able to get back on her parents’ insurance, thanks to a provision of the health care law that lets young adults keep that coverage until they turn 26. Nationally an estimated 2.5 million young people have gotten insurance as a result.

Ames says it’s unclear if the student health insurance she had been relying on previously would have covered her surgery. In any case, the copayments would have been steep. She would have had to postpone the operation, risking another — potentially crippling — injury.

“The fact that I was able to get on their plan is the reason I can walk today,” said Ames. “Very rarely have I had something political affect me this personally.”

___

Name: Sharon Whalen

Home: Springfield, Ill.

Age: 59

Occupation: Publisher of a weekly alternative newspaper

Insurance coverage: Small group plan.

As a co-owner of the Illinois Times, a weekly newspaper, Whalen wants to keep her small staff healthy. So she and her business partner provide them with health insurance and pay half the cost of premiums for their 10 employees.

Keeping that employee benefit is getting more and more expensive. The company saw a spike in premium costs after one employee’s child had chronic health problems.

With costs climbing, the company switched to a managed care plan with higher copays for some services in 2009. Whalen’s company also contributes less than it once did to cover the premiums of employees’ family members.

The health care law brought some relief: a tax credit for small businesses that provide health coverage. The Illinois Times qualified and received a $2,700 tax credit last year.

“We see ourselves putting that money right back into the company,” Whalen said.

Whalen heard about the tax credit from a health care advocacy group, not from her accountant.

“I had to practically beg them to look at this,” Whalen said. “They weren’t familiar with it.”

The Obama administration has proposed expanding the number of businesses eligible for the credit, and simplifying the paperwork.

___

Name: Melissa Pearson

Home: Prineville, Ore.

Age: 53

Occupation: Retail sales, part time.

Insurance coverage: High-deductible plan purchased on individual market.

A few years ago, Pearson’s doctor ordered her to have a routine colonoscopy. It’s one of several colon cancer screening methods highly recommended for adults ages 50 to 75.

Pearson kept putting it off, in part because of the cost. Her high-deductible health insurance plan requires her to pay the first $5,600 out of her pocket each year. She knew the colonoscopy would be expensive and figured she’d be paying.

Then she learned that a provision in the health care law requires health plans to cover all costs for preventive care including colon cancer screening — with no out-of-pocket costs to the patient.

“That’s what made me make the appointment,” she said. She also scheduled a mammogram and cervical cancer screening, which also are covered preventive services under the law. In all, she saved nearly $3,000 in out-of-pocket costs last year because of the Affordable Care Act.

“I said to my sister, ‘Thank you Obamacare,” Pearson said.

The Obama administration says the Affordable Care Act provided about 54 million Americans with at least one new free preventive service last year through their private health insurance plans.

But Pearson is worried that covering preventive services will mean her insurance premiums and her taxes will go up. “It’s being paid for by somebody,” she reasoned. She recently talked with a student from Norway who told her about the tax levels in that country. “I’m fearful our world will turn into that.”

___

Name: David Zoltan

Home: Chicago

Age: 34

Occupation: Field marketing coordinator for a public relations firm.

Insurance coverage: Federally funded health plan for people with pre-existing conditions.

Zoltan lost a job and his health insurance during the recession. His diabetes sent him to the emergency room three times when he ran out of insulin during the two years he was uninsured.

In 2010, he was one of the first to sign up in Illinois for a new health insurance program for people with pre-existing conditions. The Affordable Care Act set aside $196 million for the state of Illinois to start the program.

Zoltan now pays about $1,848 a year for that coverage. The plan has a $2,000 deductible, meaning Zoltan also pays that amount out of pocket before the coverage starts.

Zoltan has found work, but his new job doesn’t include health benefits, so he’ll stay on the federally funded health plan.

“As a diabetic, I never again want to be without health insurance,” Zoltan said. “Anything is better than not having coverage at all.”

He is watching the Supreme Court as it considers the law. The requirement that Americans buy health insurance is under constitutional scrutiny. Zoltan believes the individual mandate is needed to spread the risk among the well and the sick, and keep insurance affordable.

___

Name: Carol McKenna

Home: Pembroke Pines, Fla.

Age: 70

Occupation: Retired.

Insurance coverage: Medicare Advantage plan.

McKenna and her husband Morty have noticed that Medicare’s “doughnut hole” is shrinking. The coverage gap in Medicare’s prescription drug program — dubbed the “doughnut hole” — caught Morty in December last year. But once there, he received a 50 percent discount on brand-name drugs and other discounts on generic drugs thanks to Obama’s health care law.

Last year, he received a $250 rebate check provided by the new law for people in the doughnut hole. Under the health care law, the gap will be gradually phased out by 2020.

Warnings about possible cuts to Medicare Advantage plans caused by the health care law haven’t come true, Carol McKenna said. Their health plan still includes extra benefits such as fitness center membership.

She said she’s grown weary of the political debate over the health care law.

“I’ve been following it somewhat. Then it got so convoluted and out of control during the elections that I stopped paying attention,” McKenna said. “I don’t want to hear it anymore. All they’re doing is sniping at each other.”

___

Alonso-Zaldivar reported from Washington.

Here are snapshots of seven Americans:

___

Name: Michael Esch

Home: Warwick, N.Y.

Age: 48

Occupation: Former middle manager for medical device company, now working as a hospital purchasing agent.

Insurance coverage: Paying out of his own pocket for COBRA insurance through his former company.

Esch, a father of three, lost his job in November in a layoff his employer said resulted from President Barack Obama’s health care law. Medical device maker Stryker Corp. announced in November it intended to lay off 1,000 workers worldwide to save money ahead of a 2.3 percent tax on medical devices that starts in 2013.

The tax on medical devices is meant to help pay for expanding health coverage to uninsured Americans. The Obama administration argues device companies will gain in the long run as more patients become eligible to receive their products because they have insurance.

Esch was a middle manager who had worked for Stryker for six years. He helped develop a product known as the Triathlon Knee. Since the layoff, he’s taken a salary cut to work as a hospital purchasing agent. He’s still looking for a job with another medical device company.

He blames the medical device tax for the loss of his job, but he’s grateful for the provision in the health care law that will allow his oldest child, now a college sophomore, to stay on his health insurance to age 26.

“We tend to forget that for every great idea there is a ripple effect through other sectors of a business,” Esch said.

Economists say most companies should be able to pass on the bulk of the tax to customers, but the industry says it will squeeze profits and chill investment, hiring and innovation.

___

Name: Glenn Nishimura

Home: Little Rock, Ark.

Age: 62

Occupation: Consultant to nonprofit groups.

Insurance coverage: Uninsured since COBRA coverage from a previous job expired in May of 2009.

Nishimura has been uninsured for nearly three years. He lost his health coverage after he left a full-time position with benefits in 2007, thinking he could land another good job. The recession destroyed that plan.

He’s been denied coverage because of high blood pressure and high blood-sugar levels. A provision in the national health care law gave his state $46 million to insure people like him who’ve been denied coverage because of pre-existing conditions.

But Nishimura said he can’t afford the coverage. It would cost him about $6,300 a year in premiums with a $1,000 deductible, meaning he would pay the first $1,000 out of his own pocket before coverage kicks in.

He worries about suffering injuries in a car accident or falling ill before he’s eligible for Medicare at age 65.

“I don’t like feeling vulnerable like this,” Nishimura said. “I’m completely vulnerable to some catastrophic problem.”

Nationally, about 50,000 people with pre-existing conditions have signed up for the coverage available through the health care law, fewer than expected. The government has offered new options to encourage more to enroll. In another two years, he may be eligible for subsidies under the law for insurance.

___

Name: Samantha Ames

Home: Washington, D.C.

Age: 25

Occupation: Law student

Insurance coverage: Got back on parents’ insurance, thanks to the health care law.

As a teenager, Ames was prone to ankle injuries playing catcher on baseball and softball teams. Last April, she tripped over her mini bulldog and badly injured her left ankle. Ultimately she needed surgery that cost her insurer $30,000.

But she considers herself lucky.

Only a few months before her accident, Ames had been able to get back on her parents’ insurance, thanks to a provision of the health care law that lets young adults keep that coverage until they turn 26. Nationally an estimated 2.5 million young people have gotten insurance as a result.

Ames says it’s unclear if the student health insurance she had been relying on previously would have covered her surgery. In any case, the copayments would have been steep. She would have had to postpone the operation, risking another — potentially crippling — injury.

“The fact that I was able to get on their plan is the reason I can walk today,” said Ames. “Very rarely have I had something political affect me this personally.”

___

Name: Sharon Whalen

Home: Springfield, Ill.

Age: 59

Occupation: Publisher of a weekly alternative newspaper

Insurance coverage: Small group plan.

As a co-owner of the Illinois Times, a weekly newspaper, Whalen wants to keep her small staff healthy. So she and her business partner provide them with health insurance and pay half the cost of premiums for their 10 employees.

Keeping that employee benefit is getting more and more expensive. The company saw a spike in premium costs after one employee’s child had chronic health problems.

With costs climbing, the company switched to a managed care plan with higher copays for some services in 2009. Whalen’s company also contributes less than it once did to cover the premiums of employees’ family members.

The health care law brought some relief: a tax credit for small businesses that provide health coverage. The Illinois Times qualified and received a $2,700 tax credit last year.

“We see ourselves putting that money right back into the company,” Whalen said.

Whalen heard about the tax credit from a health care advocacy group, not from her accountant.

“I had to practically beg them to look at this,” Whalen said. “They weren’t familiar with it.”

The Obama administration has proposed expanding the number of businesses eligible for the credit, and simplifying the paperwork.

___

Name: Melissa Pearson

Home: Prineville, Ore.

Age: 53

Occupation: Retail sales, part time.

Insurance coverage: High-deductible plan purchased on individual market.

A few years ago, Pearson’s doctor ordered her to have a routine colonoscopy. It’s one of several colon cancer screening methods highly recommended for adults ages 50 to 75.

Pearson kept putting it off, in part because of the cost. Her high-deductible health insurance plan requires her to pay the first $5,600 out of her pocket each year. She knew the colonoscopy would be expensive and figured she’d be paying.

Then she learned that a provision in the health care law requires health plans to cover all costs for preventive care including colon cancer screening — with no out-of-pocket costs to the patient.

“That’s what made me make the appointment,” she said. She also scheduled a mammogram and cervical cancer screening, which also are covered preventive services under the law. In all, she saved nearly $3,000 in out-of-pocket costs last year because of the Affordable Care Act.

“I said to my sister, ‘Thank you Obamacare,” Pearson said.

The Obama administration says the Affordable Care Act provided about 54 million Americans with at least one new free preventive service last year through their private health insurance plans.

But Pearson is worried that covering preventive services will mean her insurance premiums and her taxes will go up. “It’s being paid for by somebody,” she reasoned. She recently talked with a student from Norway who told her about the tax levels in that country. “I’m fearful our world will turn into that.”

___

Name: David Zoltan

Home: Chicago

Age: 34

Occupation: Field marketing coordinator for a public relations firm.

Insurance coverage: Federally funded health plan for people with pre-existing conditions.

Zoltan lost a job and his health insurance during the recession. His diabetes sent him to the emergency room three times when he ran out of insulin during the two years he was uninsured.

In 2010, he was one of the first to sign up in Illinois for a new health insurance program for people with pre-existing conditions. The Affordable Care Act set aside $196 million for the state of Illinois to start the program.

Zoltan now pays about $1,848 a year for that coverage. The plan has a $2,000 deductible, meaning Zoltan also pays that amount out of pocket before the coverage starts.

Zoltan has found work, but his new job doesn’t include health benefits, so he’ll stay on the federally funded health plan.

“As a diabetic, I never again want to be without health insurance,” Zoltan said. “Anything is better than not having coverage at all.”

He is watching the Supreme Court as it considers the law. The requirement that Americans buy health insurance is under constitutional scrutiny. Zoltan believes the individual mandate is needed to spread the risk among the well and the sick, and keep insurance affordable.

___

Name: Carol McKenna

Home: Pembroke Pines, Fla.

Age: 70

Occupation: Retired.

Insurance coverage: Medicare Advantage plan.

McKenna and her husband Morty have noticed that Medicare’s “doughnut hole” is shrinking. The coverage gap in Medicare’s prescription drug program — dubbed the “doughnut hole” — caught Morty in December last year. But once there, he received a 50 percent discount on brand-name drugs and other discounts on generic drugs thanks to Obama’s health care law.

Last year, he received a $250 rebate check provided by the new law for people in the doughnut hole. Under the health care law, the gap will be gradually phased out by 2020.

Warnings about possible cuts to Medicare Advantage plans caused by the health care law haven’t come true, Carol McKenna said. Their health plan still includes extra benefits such as fitness center membership.

She said she’s grown weary of the political debate over the health care law.

“I’ve been following it somewhat. Then it got so convoluted and out of control during the elections that I stopped paying attention,” McKenna said. “I don’t want to hear it anymore. All they’re doing is sniping at each other.”

___

Alonso-Zaldivar reported from Washington.

Nearly 15 inches was expected across parts of northern Indiana by mid-day, and residents in Michigan’s Upper Peninsula were bracing for more than a foot before the storm continued its eastward roll through Ohio and into New England.

In a typical year, such a storm would hardly register in the Upper Midwest. But the atmospheric patterns, including the Pacific pattern known as La Nina, that have conspired to make this an unusually icy winter in Alaska have kept it abnormally warm in parts of the lower 48 states used to more snow.

For Steve Longo, a 47-year-old chiropractor from Wauwatosa, Wis., the wait to try out the cross country skis he got for Christmas was excruciating. He and friend Alex Ng, 56, wasted no time in hitting the trails at the Lapham Peak cross country ski area, about 25 miles west of Milwaukee.

“I wasn’t worried,” Longo said. “I was just anxious.”

“This is Wisconsin,” a confident Ng said. “There’s going to be snow.”

The storm left 2 to 6 inches of snow on eastern Iowa by Thursday evening, and was expected to drop 3 to 8 inches total on southern Wisconsin and northern Illinois as it moves further into the Northeast on Friday, according to Richard Castro, a National Weather Service meteorologist.

While the dry weather has been an unexpected boon to many cash-strapped communities, which have saved big by not having to pay for plowing, salting and sanding their streets, it has hurt seasonable businesses that bank on the snow.

“If people don’t see it in their yards they are not likely to come out and ski and snowboard so this is wonderful, wonderful, wonderful for us,” Kim Engel, owner of Sunburst Ski area in Kewaskum in southeastern Wisconsin, said as she watched the snow come down out the window.

Rob Moser, a snowplow driver from Elkhart, Ind., said he couldn’t wait for the flakes to start falling. The weather service said lake effect snow could mean parts of Michigan and northern Indiana could get up to a foot.

“I love it. I make money plowing snow and I’m all about snowmobiling, so I love it,” Moser said. “We haven’t had enough snow to do much.”

The storm was an annoyance for most commuters, and authorities said it caused hundreds of traffic accidents and at least three road deaths — two in Iowa and one in Missouri. And while some lucky grade-schoolers cheered an unexpected day of sledding, hundreds of would-be air travelers had to scramble to come up with a Plan B.

More than 400 flights were canceled at O’Hare International Airport in Chicago on Thursday, according to the Chicago Department of Aviation. Across town at Midway International Airport, more than 100 flights were canceled.

In New York state, the storm dumped up to 8 inches of snow on the southern Adirondack Mountains and forced scores of schools to cancel or delay the start of classes. Until Thursday’s storm, Albany had received only 6.5 inches of snow this winter, which is about 10 inches less than it normally gets, according to the weather service.

The ice and snow may have caused headaches for travelers, but 44-year-old Mike Norman, of Evanston, Ill., said the snow was long overdue. Norman co-founded Chicago Endurance Sports, which offers a Winter Warriors program to help runners stay committed to their training and teach them about the right gear for winter.

But because of the unseasonably warm weather — temperatures exceeded 50 degrees on Wednesday — the program hasn’t really geared up, he said.

“It’s one of my favorite times of year to run. It’s clean. It’s crisp. It’s quiet,” Norman said. “It’s fun to put footsteps in the fresh snow.”

Lisa Taylor, the director of the North American Vasa cross-country ski race near Traverse City, Mich., said the storm, which pushed into the area Thursday night, would help reinforce the thick base of snow on the rolling trails that they needed for races.

“There’s been a great feeling of confidence that we’d get some good snow,” Taylor said. “Up in the hilly areas where the trails are, there’s already more snow than you’d think.”

___

Associated Press writers Carrie Antlfinger in Milwaukee; Jim Salter in St. Louis; Chris Carola in Albany, N.Y.; Caryn Rousseau in Chicago; Tom Coyne in South Bend, Ind.; Carrie Schedler in Indianapolis; John Flesher in Traverse City, Mich.; Roger Schneider in Milwaukee; and Melanie Welte in Des Moines, Iowa, contributed to this report.

Mayor Rahm Emanuel’s challenge is to keep order and showcase the city to the world, while also allowing protesters with varying agendas to have a voice. Top aides to the mayor promised Thursday that the city would protect protesters’ freedoms and even go so far as to provide plenty of portable toilets and sound amplification systems to them.

“As the city of Chicago issues permits for these events, we stand is strong support of the applicant organizations’ First Amendment right to protest,” Emanuel said in a statement.

At an unusual briefing for reporters held Thursday at City Hall, officials and the head of the summit host committee released more details about planning for the gatherings, which have drawn massive and unruly protests elsewhere. But much remains uncertain, including the official site of many summit events and U.S. Secret Service security perimeters.

Details such as road closures and parking restrictions may not be known until two to four weeks before the event, said Frank Benedetto of the Secret Service’s Chicago field office in a statement.

The host committee and the city have estimated the summits could cost $40 million to $65 million and will be paid by donations from the private sector and federal funds, not by local taxpayers. Officials would not release fundraising goals.

The briefing came days before two Chicago City Council committees are expected to consider proposed security measures related to the NATO and G-8 summits. On Thursday, city officials said they’ve revised some of those proposals to respond to critics worried about infringements to First Amendment rights.

For example, they are dropping a proposal to raise the maximum fine for a violation of the parade ordinance and eliminating a requirement for parade marshals for every 100 participants. They are leaving the time of a parade at two hours and 15 minutes, instead of cutting it to two hours.

Another proposed ordinance would give the Chicago police chief the power to deputize trained law enforcement officers from other states to help with security, close public parks two hours longer than usual each day, and speed up certain procurement requirements to deal with last-minute purchasing needs.

So far, two groups have submitted four requests for permits for protest events, and Emanuel’s office announced the approval of the first such permit Thursday. It went to the Coalition Against the NATO/G-8 War and Poverty Agenda, also called CANG8.

City officials said Thursday they’ll approve two other permits soon, one for a rally planned by CANG8 and another for an event planned by National Nurses United, the nation’s largest nurses union. A fourth permit request, also from the nurses group, will be denied because it conflicts with CANG8′s Daley Plaza event, officials said, but they’ll work to find the nurses an alternative site.

The Secret Service will oversee security for the summits and may designate security zones that impact the protest permits. If that happens, the mayor said, the city pledges to work with protesters to find other rally sites and protest routes.

The mayor’s promise wasn’t enough for activists. Protest leader Andy Thayer said Thursday the city’s pledge of an alternate route if the Secret Service plans a security zone for the approved route is an unacceptable “escape clause.”

“We reject the notion that the Secret Service should reject permits that have already been approved,” Thayer said in a statement.

Like many Americans, Dunphy has a high-deductible insurance plan. He hadn’t spent his deductible yet. So, on top of his $400 monthly premium, he had to pay the bill.

“That’s bait and switch,” Dunphy said. “If it isn’t fraud, it’s immoral.”

President Barack Obama’s health overhaul encourages prevention by requiring most insurance plans to pay for preventive care. On the plus side, more than 22 million Medicare patients and many more Americans with private insurance have received one or more free covered preventive services this year. From cancer screenings to flu shots, many services no longer cost patients money.

But there are confusing exceptions. As Dunphy found out, colonoscopies can go from free to pricey while the patient is under anesthesia.

Breast cancer screenings can cause confusion too. In Florida, Tampa Bay-area small business owner Dawn Thomas, 50, went for a screening mammogram. But she was told by hospital staff that her mammogram would be a diagnostic test — not preventive screening — because a previous mammogram had found something suspicious. (It turned out to be nothing.)

Knowing that would cost her $700, and knowing her doctor had ordered a screening mammogram, Thomas stood her ground.

“Either I get a screening today or I’m putting my clothes back on and I’m leaving,” she remembers telling the hospital staff. It worked. Her mammogram was counted as preventive and she got it for free.

“A lot of women … are getting labeled with that diagnostic code and having to pay year after year for that,” Thomas said. “It’s a loophole so insurance companies don’t have to pay for it.”

For parents with several children, costs can pile up with unexpected copays for kids needing shots. Even when copays are inexpensive, they can blemish a patient-doctor relationship. Robin Brassner of Jersey City, N.J., expected her doctor visit to be free. All she wanted was a flu shot. But the doctor charged her a $20 copay.

“He said no one really comes in for just a flu shot. They inevitably mention another ailment, so he charges,” Brassner said. As a new patient, she didn’t want to start the relationship by complaining, but she left feeling irritated. “Next time, I’ll be a little more assertive about it,” she said.

How confused are doctors?

“Extremely,” said Cheryl Gregg Fahrenholz, an Ohio consultant who works with physicians. It’s common for doctors to deal with 200 different insurance plans. And some older plans are exempt.

Should insurance now pay for aspirin? Aspirin to prevent heart disease and stroke is one of the covered services for older patients. But it’s unclear whether insurers are supposed to pay only for doctors to tell older patients about aspirin — or whether they’re supposed to pay for the aspirin itself, said Dr. Jason Spangler, chief medical officer for the nonpartisan Partnership for Prevention.

Stop-smoking interventions are also supposed to be free. “But what does that mean?” Spangler asked. “Does it mean counseling? Nicotine replacement therapy? What about drugs (that can help smokers quit) like Wellbutrin or Chantix? That hasn’t been clearly laid out.”

But the greatest source of confusion is colonoscopies, a test for the nation’s second leading cancer killer. Doctors use a thin, flexible tube to scan the colon and they can remove precancerous growths called polyps at the same time. The test gets credit for lowering colorectal cancer rates. It’s one of several colon cancer screening methods highly recommended for adults ages 50 to 75.

But when a doctor screens and treats at the same time, the patient could get a surprise bill.

“It erodes a trust relationship the patients may have had with their doctors,” said Dr. Joel Brill of the American Gastroenterological Association. “We get blamed. And it’s not our fault,”

Cindy Holtzman, an insurance agent in Marietta, Ga., is telling clients to check with their insurance plans before a colonoscopy so they know what to expect.

“You could wake up with a $2,000 bill because they find that little bitty polyp,” Holtzman said.

Doctors and prevention advocates are asking Congress to revise the law to waive patient costs — including Medicare copays, which can run up to $230 — for a screening colonoscopy where polyps are removed. The American Gastroenterological Association and the American Cancer Society are pushing Congress fix the problem because of the confusion it’s causing for patients and doctors.

At least one state is taking action. After complaints piled up in Oregon, insurance regulators now are working with doctors and insurers to make sure patients aren’t getting surprise charges when polyps are removed.

Florida’s consumer services office also reports complaints about colonoscopies and other preventive care. California insurance broker Bonnie Milani said she’s lost count of the complaints she’s had about bills clients have received for preventive services.

“‘Confusion’ is not the word I’d apply to the medical offices producing the bills,” Milani said. “The word that comes to mind for me ain’t nearly so nice.”

When it’s working as intended, the new health law encourages more patients to get preventive care. Dr. Yul Ejnes, a Rhode Island physician, said he’s personally told patients with high deductible plans about the benefit. They weren’t planning to schedule a colonoscopy until they heard it would be free, Ejnes said.

If too many patients get surprise bills, however, that advantage could be lost, said Stephen Finan of the American Cancer Society Cancer Action Network. He said it will take federal or state legislation to fix the colonoscopy loophole.

Dunphy, the Phoenix businessman, recalled how he felt when he got his colonoscopy bill, like something “underhanded” was going on.

“It’s the intent of the law is to cover this stuff,” Dunphy said. “It really made me angry.”

___

AP Medical Writer Carla K. Johnson can be reached at http://www.twitter.com/CarlaKJohnson