Underwriting the Social Contract: Distributive Justice & Health Care Reform
The Jam Statement
As health care costs climbed exponentially in the 1980’s, so did the cost of health insurance plans. As a result, employers began to enroll their employees in managed care organizations, and many Americans were forced to leave their old-fashioned indemnity type plans. With the advent of the health maintenance organization, there is a financial incentive for the underutilization of care. (Blumstein, 1996; Davis & Shoen, 1996).
In order to slice financial risk, health insurance companies have restricted enrollment to individuals in terrible health. By covering the minimal standards of treatment and excluding high risk groups altogether, major US insurance companies have realized that the health insurance market can a be an extremely splendid industry. The public sector absorbs the cost of unreimbursed care for chronic care in America (Robert Wood Johnson Foundation, 1996). Based upon these findings, it seems determined that the money being removed from the health care marketplace is fattening the pockets of CEOs and majority stockholders.
Fresh trend towards localized government leaves individuals without a financial safety accept. This is the least efficient manner to handle health care costs, and evades the premise that medical care is a natural suitable in a civilized society. Few Americans feel fetch within the fresh system. The rising costs of medical care contributed to the new market changes in both the administration and delivery of health services. The financial incentive to screen only the healthiest individuals ignores the fact that medical care is a social noble.
Health Insurance Portability Act of 1996
Two years after the Clinton Health Thought was defeated in Congress, Senator Ted Kennedy and Nancy Kassebaum introduced the Kennedy-Kassebaum Bill in response to growing concerns about selective enrollment procedures veteran by health insurance companies in the private sector. In the final version of the Bill, insurance companies must limit preexisting condition clauses to twelve months. It has been estimated that this provision of the Bill will abet an estimated 150,000 Americans fetch health insurance coverage.
There are many levels of the underinsured, including those without any coverage; effective policy must address the needs of the total population without shifting costs from one disadvantaged person to another. Kennedy-Kassebaum fails to address the cost issue—the essential difficulty for those at risk for losing their health insurance. It does nothing to befriend the uninsured accept a decent health policy, and then provides no solution to the indispensable assure at hand— cost
Since Kennedy-Kassebaum does nothing to control the cost of health insurance and medical care in America, the Bill fails to answer to the negate of greatest effort to the citizens of this country: the cost of medical care. The Bill looks towards the states to accomplish consumer protections and weakens the regulatory role of the federal government. The majority of the American public is unaware of the care for footwork alive to with this legislation, and the demographics of the population it is intended to protect. In order to assess the utility of this Bill, it is necessary to identify the populations at risk for loosing health insurance coverage and the underinsured.
Kassebaum-Kennedy focuses on a slim allotment of the uninsured population, and those who would be eligible for COBRA continuation (Consolidated Omnibus Reconciliation Act of 1974). Of the 41 million uninsured Americans, only about 150,000 are expected to succor from this legislation. The Health Insurance Portability and Accountability Act of 1996 is really nothing more than smoke and mirrors since it fails to address the just deny at hand—the simple fact that the cost of quality health care in America is becoming a privilege that only the wealthy can afford.
The Cost of Care for Pre-existing Conditions
An individual with high blood pressure may honest require prescription medication. Cancer patients in remission may require chemotherapy, and a person suffering with a degenerative disease may be keen in treatment studies. Each condition requires individualized treatment that cannot be based upon the simple economic/cost-benefit analysis stale in the utilization review process by expansive insurance companies. Clearly, the most effective treatment for one patient may not be the best for another. The time required for utilization review may prove additional health risks and complications to a patient suffering from a chronic health condition.
Twelve months without insurance coverage may be financially devastating to some patients, and 63% of Americans have already forgone some type of medical treatment within the last year due to financial constraints. Publicity surrounding Kennedy-Kassebaum has hailed the bill as the “be all and destroy all in progressive legislation, however, in actuality it will only benefit about 150,000 people.
Novel studies have found that the majority of the uninsured population simply cannot afford to pay the premiums (Donelan et. al., 1996; Hoffman & Rice, 1996). According to their data, only 1% of the Uninsured population is due to unusual health set and exclusionary preexisting clauses, yet an overwhelming number of insured respondents reported an inability to receive medical care for chronic conditions. The majority of Americans with chronic illness are covered by some type of insurance, yet they are composed subject to the utilization review process and access problems that remark or delay medically considerable treatment (Donelan, et. al., Hoffman & Rice, 1996).
Underwriting the Solidarity Principle
Broken-down forms of insurance underwriting required that the contract explicitly spot which illness or services are not covered by the policy, in reach. If the underwriter did not specifically plot a clear condition in the contract, the insurer was held to the terms of the contract and required to pay for services utilized by the policyholder (Stone, 1994, as cited in Durant, 1996).
Increasing numbers of for-profit and non-profit insurance companies began to control costs by refusing to insure individuals who they felt would spend more services. Insurers began to require health eye position questionnaires (refer to attachment A), and even began implementing AIDS and genetic testing to identify high-risk individuals (Brunetta, as cited in Gutmann & Thompson, 1996). In the 1980s, sizable insurance companies began including sexual orientation as a high-risk category, by using actuarial sound criteria. Such criteria concluded that contented men were a higher risk for contracting AIDS virus and refused to write policies for anyone believed to be homosexual, (Stone, 1994 as cited in Durant, 1996).
By limiting enrollment to the healthiest members of society, selective enrollment undermines the solidarity principle of health insurance (Davis & Shoen, 1996; Snow, 1996; Stone, 1994). By eliminating those who were suspect of using more services than their healthier counterparts consume, insurance companies are able to offer rock bottom prices for young, healthy individuals. By excluding preexisting conditions and requiring clear individuals to buy high-risk policies, the number of uninsured and underinsured Americans continues to grow exponentially (Durant, 1996).
More individuals are choosing not to capture insurance simply because they cannot afford it. Even among those with employer based health coverage, the policies frequently exclude coverage for long-term illness or care of chronic conditions (MSNBC News Forum, 1996). Without a standard definition of preexisting conditions, these clauses assist as “wildcards” since they allow insurers to teach coverage for any illness that “manifested itself before the issuing date of the policy (Stone, 1994 as cited in Durant, 1996).
This statement allows insurers to yelp treatment for benefits and services for the policyholder for undiagnosed illnesses or conditions of which they were unaware. As a result, the insurers began to inquire of medical histories of applicants and their families in order to identify high risk individuals (please refer to attachment A).
Legitimacy of Distributive Justice
While there is a legitimate role of government to distribute scarce resources among the nation’s neediest individuals, sadly this is not the cause for the mismanagement of medical dollars in the United States today. There is a titanic distinction between an individual being denied prescription medication at their local pharmacy due to a cost-effective formulary developed by their Managed Care Organizations (MCOs), than an individual being denied a liver transplant because healthy livers are a scarce resource. While both may have equally devastating consequences, it is more difficult to rationalize a lost life based upon rigid cost encourage analysis and utilization decisions made according to formulas and cost-benefit analysis of treatment protocols.
“The political controversy over the distribution of health care in the United States is an instructive quandary in distributive justice. Proper health is care is notable for pursuing most other things in life. Yet equal access to health care would require the government to not only redistribute resources from the rich, healthy to the unpleasant, and infirm, but also restrict the freedom of doctors and other health care providers. Such redistributions may be warranted, but to what level, and to what extent? ” Gutmann & Thompson (Page 178).
Blendon and his colleagues have reported similar findings in public view polls from 1992 and 1994 (Blendon et. al., 1992; Blendon et. al., 1994). A unusual ogle by the American Medical Association found cost to be of paramount exertion to an overwhelming number of Americans (Donelan et. aI., 1996). Of the 40 million uninsured Americans, only 1% attributes their failure to win health insurance coverage to their preexisting conditions. Among the uninsured, cost is cited as the considerable obstacle in obtaining health insurance coverage. Only 1% of the uninsured attributes their lack of coverage to a preexisting condition.
Based upon these democratic principles of distributive justice, consistent notion polls present the legitimate role and public desire for government regulation of the health care industry. It has become determined that the federal government must intervene in order to protect natural law rights, the social contract, and the Constitution of the United States. Regulation is needed to protect the individual freedoms, liberty, and the pursuit of “health, happiness, and the American Dream.”
If America is to be the “Land of Opportunity,” then clearly individual health and wellness should be an ideal to come for. Novel models of distributive justice emphasize public consensus as a legitimate role for government intervention. According to a number of studies by Blendon and his colleagues, the public has reported an overwhelming general exertion about health care in this country, (1992, 1993, 1994, 1995, 1996).
Area civil courts are backed up with cases where HMOs have violated the First Amendment (gag orders), the Fourteenth Amendment (due process), and the rights of protected classes under the Americans with Disabilities Act. Countless examples of “anecdotal” evidence appear as headlines everyday across the country. (Unusual York Times, 1996; The Unique York Daily News, 1996; Long Island Newsday, 1996; LA Times, 1996; Picayne Times, 1996; Columbia Spectator, 1996; Columbia University Report, 1996; US News & World Reports, 1996; Newsweek 1996; Healthline, 1996; The Tennessean, 1996; The Albany Times, 1996; The Nashville Scene, 1996). In their entirety, these case reports relate the human tragedy that lies beneath the web of the very worst of American capitalism: corporate greed.
Identifying Populations At-Risk
A witness by The Lewison Group in 1996 reveals insight into the private individual health insurance market. Clearly, individuals choosing to remove health insurance policies for several hundred dollars each month demand their health care needs and expenditures to exceed that amount Regardless of health area, a young healthy 25 year conventional who purchases an individual health insurance policy can question to pay well over $300.00 monthly for a health insurance policy with Empire Blue Shield Blue Unsuitable (based upon 1996 rates, original rates available from the Unusual York Space Insurance Department).
Since individual policies are not addressed in the Health Insurance Portability and Accountability Act of 1996 (HIPA), an individual policy with Blue Horrible Blue Shield of Tennessee excludes preexisting conditions for 24 months (enrollment booklet available upon interrogate). The significant markets in need of reform are the adversely selected individual insurance market, and the state’s most vulnerable populations: children; the elderly; the chronically ill; the uninsured; and the underinsured.
For the millions of individuals who have lost their employer based coverage, the cost of private health insurance is prohibitively expensive. Many individuals opt out of the individual market and apply for public assistance when the need arises. Those who have retained their health insurance coverage through their employers are being moved into managed care despite their efforts to keep their indemnity style plans (Davis & Shoen, 1996; The Lewison Group, 1996).
Access to Medical Care
As routine practice, HMOs suppose or delay care for all services that are not outright medically significant. Growing numbers of individuals have suffered irreparable pain, and many have died awaiting approval from their HMO’s (The Original York Times, 1996; Long Island Newsday, 1996; The Tennessean, 1996; Healthline, 1996). It is hardly a secret that HMOs have fallen short of their promise to provide comprehensive health care for the “whole” individual by emphasizing preventative medicine, using medical management to coordinate care. There is vast evidence that individuals with chronic conditions receive unfriendly care in HMOs.
A four-year longitudinal behold of medical outcomes found that the elderly, the abominable, and persons with chronic conditions were in better health when covered by fee-for-service plans compared with a control group covered in HMOs (Ware et. al., 1996). Unique statistics released in Washington, DC by the American Medical Association and the Robert Wood Johnson Foundation revealed the explain costs of individuals with chronic conditions story for 75% of lisp medical expenditures in the United States (Hoffman & Rice, 1996; based upon the National Medical Expenditures Survey; raw data available on CD from the Department of Health and Human Services Washington, DC). 45% of the American population suffers from at least one chronic illness.
If managed healthcare has been found to articulate inadequate care to this population, then we are looking at 100 million individuals who are potentially facing personal and financial crisis as they are moved into managed care. The public already accounts for the largest payment of train medical expenditures, which means the millions of dollars being made by for-profit insurance companies are not being circulated into the economy to support in public health costs care. The industry made a 14.8% profit in the 3rd quarter of 1996, however these medical dollars were removed from health care and broken-down to fatten the pockets of CEO’s and majority stockholders (Healthline, 1996).
Based upon a current record from the Robert Wood Johnson Foundation, the boom costs for persons with chronic conditions report 69.4% of national expenditures in personal health care (Robert Wood Johnson Foundation, 1996). Their stammer medical costs are estimated at $4672.00 annually compared with $817.00 annually for individuals with acute illness (Hoffman & Rice, 1996; based upon National Medical Expenditures Eye 1987, not adjusted for inflation). This population is the most vulnerable to complications in their health and with their source of payment. Tremendous insurance companies only provide adequate coverage for acute illness (Donelan et al., 1996; Hoffman et. al, 1996).
Medicaid Managed Care
Following Tennessee’s lead, many states have enrolled their medically indigent populations in Medicaid Managed Care Organizations (MCOs). In Daniels v. Wadley, (926 F. Supp. 1305), the court held that TennCare violated the Due Process Clause of the Fourteenth Amendment since such procedures eliminate delicate hearings and independent medical review of disputes. The court found the pattern of routine denials of care by MCOs participating in the states TennCare program to violate the Medicaid Act since it compounded the predicament of institutionalized waiting periods for medical appeals pending independent review by the Medical Review Unit (MRU), (42 U.S.C. § 1396 (a)(8)).
Furthermore, the court ordered federal injunctive protection to participants and beneficiaries because no spot law may preempt federal law by depriving individuals of their constitutional rights. The Department of Health and Human Services (HHS) was ordered to revise its utilization review procedures for TennCare recipients in keeping with the Medicaid Act (42 U.S.C. § 1396 (a) (8)) ensuring due process protections for all covered beneficiaries by requiring “services are provided with ‘reasonable promptness,’” (926 F. Supp. 1305).
This case is one of 543 civil suits pending in the plot courts for violations of the Medicaid Act (based upon a Lexis-Nexis search performed December 26, 1996). With the passing of H.R. 3507 into public law, (The Welfare Reform Bill) private citizens will earn small reprieve in the federal courts, so any attempts to have states accountable for violations of federal law will be worn at best (Denkeret. al., 1996).
Managed care has shown itself to be a farce of “medical management” in light of all the condemning evidence to the contrary. Timothy Icenogle, a medical doctor in the position of Arizona commented in 1981, “We play sort of an advocacy role. I believe the public demands something more from physicians than to objective be a blob of bureaucrats, and I consider we have to assume a stand now and then. Our role essentially as patient advocate, is to dispute them, well, honest because the insurance company is not going to pay, that is not the raze of all the resources,” (Icenogle, as cited in Gutmann & Thompson, 1996). Never has this statement been needed more than it is today. Unfortunately, as more insurance companies refuse to pay for medical treatment, fewer resources become available for patients in desperate need of financial assistance. As Think Kessler eloquently stated as she handed down her decision in Salazar v. District of Columbia, No. 93-452, December 11, 1996, “slow every fact found herein is a human face and the reality of being awful in the richest nation on earth, (936 F. Supp. Wobble op. At 3).
Perhaps most distressing is the lack of accountability for mismanaged healthcare and unpleasant denials of medically famous treatment. HMOs claim immunity under ERISA, and leaving individuals without recourse in a sea contractual language and lengthy court calendars. It is evident that individuals protected under the Medicaid Act are not fundamentally different from other populations entrapped in the maze of managed care. They are simply those who have “had their day in court.”
Due Process Protections
Since all Americans are theoretically entitled to due process protections under the constitution of the United States, it seems the federal courts are long overdue for making such a public statement. We are wasting precious time and losing millions in principal human resources as we await decisions to be handed down from space courts. The Supreme Court of the United States has agreed to hear Unique York’s interrogate for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the set of Fresh York.
When HMOs yelp care from patients, it is ludicrous to fill individual physicians liable for the utilization decisions made by decentralized corporate review boards. It is time to lift a serious stare at tort reform, and inquire of action by the Supreme Court as they near the date of Original York’s ERISA hearing. A blanket court ruling upholding Daniels v. Wadley, and Salazar v. District of Columbia is desperately needed to avoid an avalanche of liability suits filed in set courts. The court must uphold Daniels v. Wadley, and Salazar v. District of Columbia if further lives are to be saved in medicine rather than wasted away in the utilization review procedures. While we wait patiently for District of Columbia circuit court to order injunctive relief, the number of individuals suffering irreparable damage due to the systematic denial of medical care grows larger each day.
The history of Medicaid Managed Care does not provide a very optimistic witness into the future of TennCare recipients and Medicaid beneficiaries in states around the country. Dating encourage to the implementation of the Arizona Health Care Cost Containment System (AHCCCS) in 1981, there are documented cases where “people reportedly died for lack of medical treatment before their eligibility was positive,” (Varley, as cited in Gutman & Thompson, I 996). This leaves me to wonder why the states continue to enroll their most vulnerable populations into a system of managed care that has proven to be a pain.
Perhaps profitable of comment is that Arizona is the only dwelling to have voted Republican in every election since 1948—certainly provides insight into the conservative morale of the area. Although Arizona was the last site to pick up the Medicaid cost sharing incentive proposed by the federal government in 1966, it was the first status to force its medically indigent population into managed care in 1981.
Violating Federal Law
Rigid pre-certification requirements and nonspecific utilization review procedures station strategic barriers to access medical treatment and services in Health Maintenance Organizations (HMOs). Pre-certification requirements are strategic barriers incorporated into the “murky box” of utilization review that institutionalizes exclusionary waiting periods and routine denials of medically principal treatment. According to federal law, “care and services are to be provided in a manner consistent with the simplicity of administration and the best interests of recipients,” (42 U.S.C. § I 396a (a) (19)). Clearly, such rigid pre-certification requirements that complicate administrative processing and paperwork on the share of the enrolled beneficiaries is a violation of United States Code.
Furthermore, using significant care providers as a mechanism to limit access to specialists not only complicates administrative processing, but limits enrolled beneficiaries choice of health professionals beyond what is available to the general public in the geographic region (42 U.S.C. § 1 396a (a)(30)(A)). Certainly referral procedures do not “impart that recipients will have their choice of health professionals within the understanding to the extent possible and appropriate,” (42 U.S.C. § 434.29). Under this provision, it seems that any individual, especially those with chronic health conditions or disabilities should be allowed to decide a distinguished care provider with more expertise than a nurse practitioner. I will argue that a neurologist is more familiar with the novel needs of a patient with Multiple Sclerosis than a nurse practitioner is with tiny to no knowledge specific to the medical management of degenerative
Under the Medicaid Act of 1966, covered beneficiaries may appeal any utilization review decision which denies care or limits services. The Medicaid Act gives individuals the suitable to a glorious hearing in front of an just independent Medical Review Unit (MRU). Furthermore, the Medicaid Act clearly states that medical services for a Medicaid beneficiary may not be terminated until the said beneficiary receives such a hearing
Conclusion
The country as a whole must realize what Believe Kessler told her courtroom. Her words are certainly words I will not forget—certainly worth being quoted at length:
“This case is about people—children and adults who are sick, dreadful, and vulnerable—for whom life, in the memorable words of poet Langston Hughes, “ain’t been no crystal stair”. It is written in the dry and bloodless language of “the Iaw”—statistics, acronyms of agencies and bureaucratic entities, Supreme Court case names and quotes, official governmental reports, periodicity tables, etc. But let there be no forgetting the loyal people to whom this bloodless language gives voice: anxious working parents who are too awful to glean medications or heart catheter procedures or lead poisoning screening for their children, AIDS patients unable to find treatment, elderly persons suffering from chronic conditions like diabetes and heart disease who require constant monitoring arid medical attention. Slow every fact found herein is a human face and the reality of being terrible in the richest nation on earth. (Perambulate op. At 3). -Judge Gladys Kessler, December 11, 1996.
Patients are routinely being denied medical care– and being forced into a system that incorporates long waiting periods into their physician contracts and handbooks (Green, 1996). The private for-profit insurance industry has single-handedly undermined the solidarity principle of health insurance by using strict underwriting techniques, ridiculous treatment protocols; inconsistent definitions of chronic illness and rigid utilization review procedures unavailable to the consumer; and inconsistent definitions of “chronic illness” and “emergency” (Dallek, 1996). It is an industry which justified using sexual orientation to avoid covering AIDS patients, calling such methods “actuarially sound.” The privatization of a public expedient has removed millions of dollars from the healthcare marketplace with “medical loss ratios” of 57% compared to 85% in the conventional health insurance market
Although a slim part of the general public is unable to bag health insurance coverage due to a preexisting condition, the more necessary narrate remains the cost of coverage. The cost of medical care will remain an protest since unique legislative efforts evade the thunder. Original changes in the delivery of health services is of grave disaster and different options must be considered in order to catch more effective ways to provide public and private assistance—MANAGED CARE IS NOT THE Reply!!! FOR-PROFIT HEALTH CARE IS NOT THE Respond! PRIVATIZATION IS NOT THE Retort!
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Underwriting the Social Contract: Distributive Justice & Health Care Reform
The Pickle Statement
As health care costs climbed exponentially in the 1980’s, so did the cost of health insurance plans. As a result, employers began to enroll their employees in managed care organizations, and many Americans were forced to leave their former indemnity type plans. With the advent of the health maintenance organization, there is a financial incentive for the underutilization of care. (Blumstein, 1996; Davis & Shoen, 1996).
In order to chop financial risk, health insurance companies have restricted enrollment to individuals in abominable health. By covering the minimal standards of treatment and excluding high risk groups altogether, major US insurance companies have realized that the health insurance market can a be an extremely helpful industry. The public sector absorbs the cost of unreimbursed care for chronic care in America (Robert Wood Johnson Foundation, 1996). Based upon these findings, it seems distinct that the money being removed from the health care marketplace is fattening the pockets of CEOs and majority stockholders.
Novel trend towards localized government leaves individuals without a financial safety regain. This is the least efficient manner to handle health care costs, and evades the premise that medical care is a natural apt in a civilized society. Few Americans feel win within the recent system. The rising costs of medical care contributed to the modern market changes in both the administration and delivery of health services. The financial incentive to screen only the healthiest individuals ignores the fact that medical care is a social gracious.
Health Insurance Portability Act of 1996
Two years after the Clinton Health Understanding was defeated in Congress, Senator Ted Kennedy and Nancy Kassebaum introduced the Kennedy-Kassebaum Bill in response to growing concerns about selective enrollment procedures worn by health insurance companies in the private sector. In the final version of the Bill, insurance companies must limit preexisting condition clauses to twelve months. It has been estimated that this provision of the Bill will benefit an estimated 150,000 Americans derive health insurance coverage.
There are many levels of the underinsured, including those without any coverage; effective policy must address the needs of the total population without shifting costs from one disadvantaged person to another. Kennedy-Kassebaum fails to address the cost issue—the valuable grief for those at risk for losing their health insurance. It does nothing to serve the uninsured accept a decent health policy, and then provides no solution to the significant stammer at hand— cost
Since Kennedy-Kassebaum does nothing to control the cost of health insurance and medical care in America, the Bill fails to retort to the insist of greatest anxiety to the citizens of this country: the cost of medical care. The Bill looks towards the states to obtain consumer protections and weakens the regulatory role of the federal government. The majority of the American public is unaware of the worship footwork keen with this legislation, and the demographics of the population it is intended to protect. In order to assess the utility of this Bill, it is considerable to identify the populations at risk for loosing health insurance coverage and the underinsured.
Kassebaum-Kennedy focuses on a slim fragment of the uninsured population, and those who would be eligible for COBRA continuation (Consolidated Omnibus Reconciliation Act of 1974). Of the 41 million uninsured Americans, only about 150,000 are expected to support from this legislation. The Health Insurance Portability and Accountability Act of 1996 is really nothing more than smoke and mirrors since it fails to address the accurate notify at hand—the simple fact that the cost of quality health care in America is becoming a privilege that only the wealthy can afford.
The Cost of Care for Pre-existing Conditions
An individual with high blood pressure may unprejudiced require prescription medication. Cancer patients in remission may require chemotherapy, and a person suffering with a degenerative disease may be eager in treatment studies. Each condition requires individualized treatment that cannot be based upon the simple economic/cost-benefit analysis worn in the utilization review process by substantial insurance companies. Clearly, the most effective treatment for one patient may not be the best for another. The time required for utilization review may exhibit additional health risks and complications to a patient suffering from a chronic health condition.
Twelve months without insurance coverage may be financially devastating to some patients, and 63% of Americans have already forgone some type of medical treatment within the last year due to financial constraints. Publicity surrounding Kennedy-Kassebaum has hailed the bill as the “be all and destroy all in progressive legislation, however, in actuality it will only abet about 150,000 people.
Unique studies have found that the majority of the uninsured population simply cannot afford to pay the premiums (Donelan et. al., 1996; Hoffman & Rice, 1996). According to their data, only 1% of the Uninsured population is due to modern health position and exclusionary preexisting clauses, yet an overwhelming number of insured respondents reported an inability to receive medical care for chronic conditions. The majority of Americans with chronic illness are covered by some type of insurance, yet they are aloof subject to the utilization review process and access problems that inform or delay medically essential treatment (Donelan, et. al., Hoffman & Rice, 1996).
Underwriting the Solidarity Principle
Dilapidated forms of insurance underwriting required that the contract explicitly spot which illness or services are not covered by the policy, in approach. If the underwriter did not specifically region a determined condition in the contract, the insurer was held to the terms of the contract and required to pay for services utilized by the policyholder (Stone, 1994, as cited in Durant, 1996).
Increasing numbers of for-profit and non-profit insurance companies began to control costs by refusing to insure individuals who they felt would employ more services. Insurers began to require health search for location questionnaires (refer to attachment A), and even began implementing AIDS and genetic testing to identify high-risk individuals (Brunetta, as cited in Gutmann & Thompson, 1996). In the 1980s, immense insurance companies began including sexual orientation as a high-risk category, by using actuarial sound criteria. Such criteria concluded that elated men were a higher risk for contracting AIDS virus and refused to write policies for anyone believed to be homosexual, (Stone, 1994 as cited in Durant, 1996).
By limiting enrollment to the healthiest members of society, selective enrollment undermines the solidarity principle of health insurance (Davis & Shoen, 1996; Snow, 1996; Stone, 1994). By eliminating those who were suspect of using more services than their healthier counterparts employ, insurance companies are able to offer rock bottom prices for young, healthy individuals. By excluding preexisting conditions and requiring positive individuals to assume high-risk policies, the number of uninsured and underinsured Americans continues to grow exponentially (Durant, 1996).
More individuals are choosing not to recall insurance simply because they cannot afford it. Even among those with employer based health coverage, the policies frequently exclude coverage for long-term illness or care of chronic conditions (MSNBC News Forum, 1996). Without a standard definition of preexisting conditions, these clauses befriend as “wildcards” since they allow insurers to screech coverage for any illness that “manifested itself before the issuing date of the policy (Stone, 1994 as cited in Durant, 1996).
This statement allows insurers to assure treatment for benefits and services for the policyholder for undiagnosed illnesses or conditions of which they were unaware. As a result, the insurers began to inquire of medical histories of applicants and their families in order to identify high risk individuals (please refer to attachment A).
Legitimacy of Distributive Justice
While there is a legitimate role of government to distribute scarce resources among the nation’s neediest individuals, sadly this is not the cause for the mismanagement of medical dollars in the United States today. There is a substantial distinction between an individual being denied prescription medication at their local pharmacy due to a cost-effective formulary developed by their Managed Care Organizations (MCOs), than an individual being denied a liver transplant because healthy livers are a scarce resource. While both may have equally devastating consequences, it is more difficult to rationalize a lost life based upon rigid cost aid analysis and utilization decisions made according to formulas and cost-benefit analysis of treatment protocols.
“The political controversy over the distribution of health care in the United States is an instructive predicament in distributive justice. Favorable health is care is essential for pursuing most other things in life. Yet equal access to health care would require the government to not only redistribute resources from the rich, healthy to the terrible, and infirm, but also restrict the freedom of doctors and other health care providers. Such redistributions may be warranted, but to what level, and to what extent? ” Gutmann & Thompson (Page 178).
Blendon and his colleagues have reported similar findings in public thought polls from 1992 and 1994 (Blendon et. al., 1992; Blendon et. al., 1994). A modern inspect by the American Medical Association found cost to be of paramount pains to an overwhelming number of Americans (Donelan et. aI., 1996). Of the 40 million uninsured Americans, only 1% attributes their failure to get health insurance coverage to their preexisting conditions. Among the uninsured, cost is cited as the necessary obstacle in obtaining health insurance coverage. Only 1% of the uninsured attributes their lack of coverage to a preexisting condition.
Based upon these democratic principles of distributive justice, consistent plan polls reveal the legitimate role and public desire for government regulation of the health care industry. It has become positive that the federal government must intervene in order to protect natural law rights, the social contract, and the Constitution of the United States. Regulation is needed to protect the individual freedoms, liberty, and the pursuit of “health, happiness, and the American Dream.”
If America is to be the “Land of Opportunity,” then clearly individual health and wellness should be an ideal to approach for. Original models of distributive justice emphasize public consensus as a legitimate role for government intervention. According to a number of studies by Blendon and his colleagues, the public has reported an overwhelming general worry about health care in this country, (1992, 1993, 1994, 1995, 1996).
Plot civil courts are backed up with cases where HMOs have violated the First Amendment (gag orders), the Fourteenth Amendment (due process), and the rights of protected classes under the Americans with Disabilities Act. Countless examples of “anecdotal” evidence appear as headlines everyday across the country. (Fresh York Times, 1996; The Current York Daily News, 1996; Long Island Newsday, 1996; LA Times, 1996; Picayne Times, 1996; Columbia Spectator, 1996; Columbia University Recount, 1996; US News & World Reports, 1996; Newsweek 1996; Healthline, 1996; The Tennessean, 1996; The Albany Times, 1996; The Nashville Scene, 1996). In their entirety, these case reports characterize the human tragedy that lies beneath the web of the very worst of American capitalism: corporate greed.
Identifying Populations At-Risk
A discover by The Lewison Group in 1996 reveals insight into the private individual health insurance market. Clearly, individuals choosing to engage health insurance policies for several hundred dollars each month quiz their health care needs and expenditures to exceed that amount Regardless of health state, a young healthy 25 year weak who purchases an individual health insurance policy can seek information from to pay well over $300.00 monthly for a health insurance policy with Empire Blue Shield Blue Harmful (based upon 1996 rates, recent rates available from the Fresh York Set Insurance Department).
Since individual policies are not addressed in the Health Insurance Portability and Accountability Act of 1996 (HIPA), an individual policy with Blue Wrong Blue Shield of Tennessee excludes preexisting conditions for 24 months (enrollment booklet available upon interrogate). The notable markets in need of reform are the adversely selected individual insurance market, and the state’s most vulnerable populations: children; the elderly; the chronically ill; the uninsured; and the underinsured.
For the millions of individuals who have lost their employer based coverage, the cost of private health insurance is prohibitively expensive. Many individuals opt out of the individual market and apply for public assistance when the need arises. Those who have retained their health insurance coverage through their employers are being moved into managed care despite their efforts to preserve their indemnity style plans (Davis & Shoen, 1996; The Lewison Group, 1996).
Access to Medical Care
As routine practice, HMOs converse or delay care for all services that are not outright medically critical. Growing numbers of individuals have suffered irreparable distress, and many have died awaiting approval from their HMO’s (The Unusual York Times, 1996; Long Island Newsday, 1996; The Tennessean, 1996; Healthline, 1996). It is hardly a secret that HMOs have fallen short of their promise to provide comprehensive health care for the “whole” individual by emphasizing preventative medicine, using medical management to coordinate care. There is tall evidence that individuals with chronic conditions receive heinous care in HMOs.
A four-year longitudinal view of medical outcomes found that the elderly, the bad, and persons with chronic conditions were in better health when covered by fee-for-service plans compared with a control group covered in HMOs (Ware et. al., 1996). Original statistics released in Washington, DC by the American Medical Association and the Robert Wood Johnson Foundation revealed the mumble costs of individuals with chronic conditions story for 75% of affirm medical expenditures in the United States (Hoffman & Rice, 1996; based upon the National Medical Expenditures Survey; raw data available on CD from the Department of Health and Human Services Washington, DC). 45% of the American population suffers from at least one chronic illness.
If managed healthcare has been found to declare inadequate care to this population, then we are looking at 100 million individuals who are potentially facing personal and financial crisis as they are moved into managed care. The public already accounts for the largest payment of sing medical expenditures, which means the millions of dollars being made by for-profit insurance companies are not being circulated into the economy to befriend in public health costs care. The industry made a 14.8% profit in the 3rd quarter of 1996, however these medical dollars were removed from health care and ancient to fatten the pockets of CEO’s and majority stockholders (Healthline, 1996).
Based upon a original picture from the Robert Wood Johnson Foundation, the drawl costs for persons with chronic conditions describe 69.4% of national expenditures in personal health care (Robert Wood Johnson Foundation, 1996). Their shriek medical costs are estimated at $4672.00 annually compared with $817.00 annually for individuals with acute illness (Hoffman & Rice, 1996; based upon National Medical Expenditures View 1987, not adjusted for inflation). This population is the most vulnerable to complications in their health and with their source of payment. Enormous insurance companies only provide adequate coverage for acute illness (Donelan et al., 1996; Hoffman et. al, 1996).
Medicaid Managed Care
Following Tennessee’s lead, many states have enrolled their medically indigent populations in Medicaid Managed Care Organizations (MCOs). In Daniels v. Wadley, (926 F. Supp. 1305), the court held that TennCare violated the Due Process Clause of the Fourteenth Amendment since such procedures eliminate gorgeous hearings and independent medical review of disputes. The court found the pattern of routine denials of care by MCOs participating in the states TennCare program to violate the Medicaid Act since it compounded the dilemma of institutionalized waiting periods for medical appeals pending independent review by the Medical Review Unit (MRU), (42 U.S.C. § 1396 (a)(8)).
Furthermore, the court ordered federal injunctive protection to participants and beneficiaries because no set law may preempt federal law by depriving individuals of their constitutional rights. The Department of Health and Human Services (HHS) was ordered to revise its utilization review procedures for TennCare recipients in keeping with the Medicaid Act (42 U.S.C. § 1396 (a) (8)) ensuring due process protections for all covered beneficiaries by requiring “services are provided with ‘reasonable promptness,’” (926 F. Supp. 1305).
This case is one of 543 civil suits pending in the location courts for violations of the Medicaid Act (based upon a Lexis-Nexis search performed December 26, 1996). With the passing of H.R. 3507 into public law, (The Welfare Reform Bill) private citizens will gain exiguous reprieve in the federal courts, so any attempts to possess states accountable for violations of federal law will be ancient at best (Denkeret. al., 1996).
Managed care has shown itself to be a farce of “medical management” in light of all the condemning evidence to the contrary. Timothy Icenogle, a medical doctor in the site of Arizona commented in 1981, “We play sort of an advocacy role. I mediate the public demands something more from physicians than to objective be a blob of bureaucrats, and I mediate we have to win a stand now and then. Our role essentially as patient advocate, is to whisper them, well, fair because the insurance company is not going to pay, that is not the slay of all the resources,” (Icenogle, as cited in Gutmann & Thompson, 1996). Never has this statement been needed more than it is today. Unfortunately, as more insurance companies refuse to pay for medical treatment, fewer resources become available for patients in desperate need of financial assistance. As Assume Kessler eloquently stated as she handed down her decision in Salazar v. District of Columbia, No. 93-452, December 11, 1996, “leisurely every fact found herein is a human face and the reality of being terrible in the richest nation on earth, (936 F. Supp. Slither op. At 3).
Perhaps most distressing is the lack of accountability for mismanaged healthcare and irascible denials of medically critical treatment. HMOs claim immunity under ERISA, and leaving individuals without recourse in a sea contractual language and lengthy court calendars. It is evident that individuals protected under the Medicaid Act are not fundamentally different from other populations entrapped in the maze of managed care. They are simply those who have “had their day in court.”
Due Process Protections
Since all Americans are theoretically entitled to due process protections under the constitution of the United States, it seems the federal courts are long overdue for making such a public statement. We are wasting precious time and losing millions in important human resources as we await decisions to be handed down from spot courts. The Supreme Court of the United States has agreed to hear Unique York’s ask for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the residence of Fresh York.
When HMOs utter care from patients, it is ludicrous to believe individual physicians liable for the utilization decisions made by decentralized corporate review boards. It is time to win a serious notice at tort reform, and ask action by the Supreme Court as they advance the date of Modern York’s ERISA hearing. A blanket court ruling upholding Daniels v. Wadley, and Salazar v. District of Columbia is desperately needed to avoid an avalanche of liability suits filed in area courts. The court must uphold Daniels v. Wadley, and Salazar v. District of Columbia if further lives are to be saved in medicine rather than wasted away in the utilization review procedures. While we wait patiently for District of Columbia circuit court to order injunctive relief, the number of individuals suffering irreparable afflict due to the systematic denial of medical care grows larger each day.
The history of Medicaid Managed Care does not provide a very optimistic witness into the future of TennCare recipients and Medicaid beneficiaries in states around the country. Dating befriend to the implementation of the Arizona Health Care Cost Containment System (AHCCCS) in 1981, there are documented cases where “people reportedly died for lack of medical treatment before their eligibility was obvious,” (Varley, as cited in Gutman & Thompson, I 996). This leaves me to wonder why the states continue to enroll their most vulnerable populations into a system of managed care that has proven to be a wretchedness.
Perhaps proper of comment is that Arizona is the only dwelling to have voted Republican in every election since 1948—certainly provides insight into the conservative morale of the position. Although Arizona was the last spot to find the Medicaid cost sharing incentive proposed by the federal government in 1966, it was the first region to force its medically indigent population into managed care in 1981.
Violating Federal Law
Rigid pre-certification requirements and nonspecific utilization review procedures site strategic barriers to access medical treatment and services in Health Maintenance Organizations (HMOs). Pre-certification requirements are strategic barriers incorporated into the “sad box” of utilization review that institutionalizes exclusionary waiting periods and routine denials of medically distinguished treatment. According to federal law, “care and services are to be provided in a manner consistent with the simplicity of administration and the best interests of recipients,” (42 U.S.C. § I 396a (a) (19)). Clearly, such rigid pre-certification requirements that complicate administrative processing and paperwork on the piece of the enrolled beneficiaries is a violation of United States Code.
Furthermore, using important care providers as a mechanism to limit access to specialists not only complicates administrative processing, but limits enrolled beneficiaries choice of health professionals beyond what is available to the general public in the geographic location (42 U.S.C. § 1 396a (a)(30)(A)). Certainly referral procedures do not “shriek that recipients will have their choice of health professionals within the understanding to the extent possible and appropriate,” (42 U.S.C. § 434.29). Under this provision, it seems that any individual, especially those with chronic health conditions or disabilities should be allowed to decide a distinguished care provider with more expertise than a nurse practitioner. I will argue that a neurologist is more familiar with the current needs of a patient with Multiple Sclerosis than a nurse practitioner is with diminutive to no knowledge specific to the medical management of degenerative
Under the Medicaid Act of 1966, covered beneficiaries may appeal any utilization review decision which denies care or limits services. The Medicaid Act gives individuals the proper to a exquisite hearing in front of an objective independent Medical Review Unit (MRU). Furthermore, the Medicaid Act clearly states that medical services for a Medicaid beneficiary may not be terminated until the said beneficiary receives such a hearing
Conclusion
The country as a whole must realize what Deem Kessler told her courtroom. Her words are certainly words I will not forget—certainly worth being quoted at length:
“This case is about people—children and adults who are sick, abominable, and vulnerable—for whom life, in the memorable words of poet Langston Hughes, “ain’t been no crystal stair”. It is written in the dry and bloodless language of “the Iaw”—statistics, acronyms of agencies and bureaucratic entities, Supreme Court case names and quotes, official governmental reports, periodicity tables, etc. But let there be no forgetting the right people to whom this bloodless language gives voice: anxious working parents who are too terrible to come by medications or heart catheter procedures or lead poisoning screening for their children, AIDS patients unable to gain treatment, elderly persons suffering from chronic conditions like diabetes and heart disease who require constant monitoring arid medical attention. Gradual every fact found herein is a human face and the reality of being awful in the richest nation on earth. (Slide op. At 3). -Judge Gladys Kessler, December 11, 1996.
Patients are routinely being denied medical care– and being forced into a system that incorporates long waiting periods into their physician contracts and handbooks (Green, 1996). The private for-profit insurance industry has single-handedly undermined the solidarity principle of health insurance by using strict underwriting techniques, ridiculous treatment protocols; inconsistent definitions of chronic illness and rigid utilization review procedures unavailable to the consumer; and inconsistent definitions of “chronic illness” and “emergency” (Dallek, 1996). It is an industry which justified using sexual orientation to avoid covering AIDS patients, calling such methods “actuarially sound.” The privatization of a public honorable has removed millions of dollars from the healthcare marketplace with “medical loss ratios” of 57% compared to 85% in the conventional health insurance market
Although a slim allotment of the general public is unable to derive health insurance coverage due to a preexisting condition, the more principal assure remains the cost of coverage. The cost of medical care will remain an stutter since current legislative efforts evade the whine. Unique changes in the delivery of health services is of grave misfortune and different options must be considered in order to come by more effective ways to provide public and private assistance—MANAGED CARE IS NOT THE Respond!!! FOR-PROFIT HEALTH CARE IS NOT THE Acknowledge! PRIVATIZATION IS NOT THE Acknowledge!
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