Underwriting the Social Contract: Distributive Justice & Health Care Reform
The Predicament 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 mature 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 lop financial risk, health insurance companies have restricted enrollment to individuals in awful 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 genuine 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 sure that the money being removed from the health care marketplace is fattening the pockets of CEOs and majority stockholders.
Modern trend towards localized government leaves individuals without a financial safety win. This is the least efficient manner to handle health care costs, and evades the premise that medical care is a natural good in a civilized society. Few Americans feel derive within the novel system. The rising costs of medical care contributed to the original market changes in both the administration and delivery of health services. The financial incentive to veil only the healthiest individuals ignores the fact that medical care is a social genuine.
Health Insurance Portability Act of 1996
Two years after the Clinton Health Belief was defeated in Congress, Senator Ted Kennedy and Nancy Kassebaum introduced the Kennedy-Kassebaum Bill in response to growing concerns about selective enrollment procedures former 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 relieve an estimated 150,000 Americans regain 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 famous exertion for those at risk for losing their health insurance. It does nothing to befriend the uninsured salvage a decent health policy, and then provides no solution to the well-known snarl at hand— cost
Since Kennedy-Kassebaum does nothing to control the cost of health insurance and medical care in America, the Bill fails to acknowledge to the recount of greatest difficulty to the citizens of this country: the cost of medical care. The Bill looks towards the states to perform consumer protections and weakens the regulatory role of the federal government. The majority of the American public is unaware of the like footwork interested 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 famous to identify the populations at risk for loosing health insurance coverage and the underinsured.
Kassebaum-Kennedy focuses on a slim fraction 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 serve 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 apt whine 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 broken-down in the utilization review process by gargantuan insurance companies. Clearly, the most effective treatment for one patient may not be the best for another. The time required for utilization review may reveal 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 slay all in progressive legislation, however, in actuality it will only succor about 150,000 people.
Unusual 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 original 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 tranquil subject to the utilization review process and access problems that jabber or delay medically valuable treatment (Donelan, et. al., Hoffman & Rice, 1996).
Underwriting the Solidarity Principle
Aged forms of insurance underwriting required that the contract explicitly place which illness or services are not covered by the policy, in near. If the underwriter did not specifically residence a distinct 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 exhaust more services. Insurers began to require health glimpse space 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, mountainous insurance companies began including sexual orientation as a high-risk category, by using actuarial sound criteria. Such criteria concluded that blissful 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 expend, insurance companies are able to offer rock bottom prices for young, healthy individuals. By excluding preexisting conditions and requiring definite individuals to recall high-risk policies, the number of uninsured and underinsured Americans continues to grow exponentially (Durant, 1996).
More individuals are choosing not to assume 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 abet as “wildcards” since they allow insurers to order 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 snarl 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 query 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 great 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 relieve 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 spot in distributive justice. Honorable health is care is valuable 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 awful, 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 notion polls from 1992 and 1994 (Blendon et. al., 1992; Blendon et. al., 1994). A new behold by the American Medical Association found cost to be of paramount distress to an overwhelming number of Americans (Donelan et. aI., 1996). Of the 40 million uninsured Americans, only 1% attributes their failure to find health insurance coverage to their preexisting conditions. Among the uninsured, cost is cited as the vital 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 thought polls exhibit the legitimate role and public desire for government regulation of the health care industry. It has become sure 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 near 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 pain 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. (Recent York Times, 1996; The Recent York Daily News, 1996; Long Island Newsday, 1996; LA Times, 1996; Picayne Times, 1996; Columbia Spectator, 1996; Columbia University Represent, 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 survey by The Lewison Group in 1996 reveals insight into the private individual health insurance market. Clearly, individuals choosing to recall 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 aged who purchases an individual health insurance policy can ask to pay well over $300.00 monthly for a health insurance policy with Empire Blue Shield Blue Injurious (based upon 1996 rates, unique rates available from the Unique York Situation Insurance Department).
Since individual policies are not addressed in the Health Insurance Portability and Accountability Act of 1996 (HIPA), an individual policy with Blue Injurious Blue Shield of Tennessee excludes preexisting conditions for 24 months (enrollment booklet available upon demand). The famous 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 order or delay care for all services that are not outright medically vital. Growing numbers of individuals have suffered irreparable damage, and many have died awaiting approval from their HMO’s (The Fresh 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 tremendous evidence that individuals with chronic conditions receive outrageous care in HMOs.
A four-year longitudinal gape of medical outcomes found that the elderly, the awful, 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). Unusual statistics released in Washington, DC by the American Medical Association and the Robert Wood Johnson Foundation revealed the sigh costs of individuals with chronic conditions narrative for 75% of divulge 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 grunt 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 converse medical expenditures, which means the millions of dollars being made by for-profit insurance companies are not being circulated into the economy to relieve 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 old-fashioned to fatten the pockets of CEO’s and majority stockholders (Healthline, 1996).
Based upon a original relate from the Robert Wood Johnson Foundation, the recount costs for persons with chronic conditions relate 69.4% of national expenditures in personal health care (Robert Wood Johnson Foundation, 1996). Their roar 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 Explore 1987, not adjusted for inflation). This population is the most vulnerable to complications in their health and with their source of payment. Big 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 shapely 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 plight 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 area 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 site 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 accept tiny reprieve in the federal courts, so any attempts to gain states accountable for violations of federal law will be stale 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 spot of Arizona commented in 1981, “We play sort of an advocacy role. I assume the public demands something more from physicians than to objective be a blob of bureaucrats, and I believe we have to buy a stand now and then. Our role essentially as patient advocate, is to deliver them, well, unprejudiced because the insurance company is not going to pay, that is not the ruin 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 Deem 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 dreadful in the richest nation on earth, (936 F. Supp. Chase op. At 3).
Perhaps most distressing is the lack of accountability for mismanaged healthcare and noxious denials of medically vital 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 distinguished human resources as we await decisions to be handed down from dwelling courts. The Supreme Court of the United States has agreed to hear Unique York’s question for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the space of Novel York.
When HMOs assure care from patients, it is ludicrous to enjoy individual physicians liable for the utilization decisions made by decentralized corporate review boards. It is time to buy a serious witness at tort reform, and question action by the Supreme Court as they reach the date of Fresh 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 space 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 pain due to the systematic denial of medical care grows larger each day.
The history of Medicaid Managed Care does not provide a very optimistic peek into the future of TennCare recipients and Medicaid beneficiaries in states around the country. Dating serve 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 distinct,” (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 pleasant of comment is that Arizona is the only site to have voted Republican in every election since 1948—certainly provides insight into the conservative morale of the place. Although Arizona was the last place to score 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 region strategic barriers to access medical treatment and services in Health Maintenance Organizations (HMOs). Pre-certification requirements are strategic barriers incorporated into the “dismal 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 portion of the enrolled beneficiaries is a violation of United States Code.
Furthermore, using valuable 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 site (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 opinion 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 resolve a significant 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 fair to a ravishing 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 Consider 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, bad, 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 accurate people to whom this bloodless language gives voice: anxious working parents who are too abominable to procure medications or heart catheter procedures or lead poisoning screening for their children, AIDS patients unable to derive 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. (Hurry 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 advantageous has removed millions of dollars from the healthcare marketplace with “medical loss ratios” of 57% compared to 85% in the old-fashioned health insurance market
Although a slim part of the general public is unable to earn health insurance coverage due to a preexisting condition, the more important deny remains the cost of coverage. The cost of medical care will remain an enlighten since novel legislative efforts evade the inform. Novel changes in the delivery of health services is of grave inconvenience and different options must be considered in order to fetch more effective ways to provide public and private assistance—MANAGED CARE IS NOT THE Respond!!! FOR-PROFIT HEALTH CARE IS NOT THE Reply! PRIVATIZATION IS NOT THE Respond!
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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 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 gash 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 salubrious 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 obvious that the money being removed from the health care marketplace is fattening the pockets of CEOs and majority stockholders.
Unique trend towards localized government leaves individuals without a financial safety come by. 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 derive within the recent system. The rising costs of medical care contributed to the unusual 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 respectable.
Health Insurance Portability Act of 1996
Two years after the Clinton Health Idea was defeated in Congress, Senator Ted Kennedy and Nancy Kassebaum introduced the Kennedy-Kassebaum Bill in response to growing concerns about selective enrollment procedures venerable 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 wait on an estimated 150,000 Americans gain 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 famous worry for those at risk for losing their health insurance. It does nothing to befriend the uninsured gather a decent health policy, and then provides no solution to the valuable 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 reply to the negate of greatest anguish to the citizens of this country: the cost of medical care. The Bill looks towards the states to design consumer protections and weakens the regulatory role of the federal government. The majority of the American public is unaware of the appreciate footwork interested 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 distinguished 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 help 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 factual order 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 impartial require prescription medication. Cancer patients in remission may require chemotherapy, and a person suffering with a degenerative disease may be alive to in treatment studies. Each condition requires individualized treatment that cannot be based upon the simple economic/cost-benefit analysis broken-down 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 note 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 serve about 150,000 people.
New 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 new health situation 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 smooth subject to the utilization review process and access problems that command or delay medically important treatment (Donelan, et. al., Hoffman & Rice, 1996).
Underwriting the Solidarity Principle
Used forms of insurance underwriting required that the contract explicitly area which illness or services are not covered by the policy, in arrive. If the underwriter did not specifically space a distinct 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 exercise more services. Insurers began to require health contemplate plot 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, stout insurance companies began including sexual orientation as a high-risk category, by using actuarial sound criteria. Such criteria concluded that blissful 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 utilize, insurance companies are able to offer rock bottom prices for young, healthy individuals. By excluding preexisting conditions and requiring sure individuals to choose high-risk policies, the number of uninsured and underinsured Americans continues to grow exponentially (Durant, 1996).
More individuals are choosing not to retract 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 support as “wildcards” since they allow insurers to protest 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 snarl 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 ample 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 assist 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 pickle in distributive justice. Favorable health is care is well-known 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 dreadful, 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 original inspect by the American Medical Association found cost to be of paramount difficulty to an overwhelming number of Americans (Donelan et. aI., 1996). Of the 40 million uninsured Americans, only 1% attributes their failure to derive health insurance coverage to their preexisting conditions. Among the uninsured, cost is cited as the essential 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 concept polls show the legitimate role and public desire for government regulation of the health care industry. It has become clear 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 arrive 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 pains about health care in this country, (1992, 1993, 1994, 1995, 1996).
Site 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 Original York Daily News, 1996; Long Island Newsday, 1996; LA Times, 1996; Picayne Times, 1996; Columbia Spectator, 1996; Columbia University Describe, 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 report the human tragedy that lies beneath the web of the very worst of American capitalism: corporate greed.
Identifying Populations At-Risk
A sight 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 interrogate their health care needs and expenditures to exceed that amount Regardless of health dwelling, a young healthy 25 year conventional who purchases an individual health insurance policy can request to pay well over $300.00 monthly for a health insurance policy with Empire Blue Shield Blue Ghastly (based upon 1996 rates, original rates available from the Novel York Site Insurance Department).
Since individual policies are not addressed in the Health Insurance Portability and Accountability Act of 1996 (HIPA), an individual policy with Blue Unpleasant Blue Shield of Tennessee excludes preexisting conditions for 24 months (enrollment booklet available upon inquire). The famous 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 sustain their indemnity style plans (Davis & Shoen, 1996; The Lewison Group, 1996).
Access to Medical Care
As routine practice, HMOs disclose or delay care for all services that are not outright medically principal. Growing numbers of individuals have suffered irreparable distress, and many have died awaiting approval from their HMO’s (The Current 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 enormous evidence that individuals with chronic conditions receive sinful care in HMOs.
A four-year longitudinal eye of medical outcomes found that the elderly, the terrible, 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). Current statistics released in Washington, DC by the American Medical Association and the Robert Wood Johnson Foundation revealed the inform costs of individuals with chronic conditions epic for 75% of stutter 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 hiss 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 allege medical expenditures, which means the millions of dollars being made by for-profit insurance companies are not being circulated into the economy to abet 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 unique portray from the Robert Wood Johnson Foundation, the teach costs for persons with chronic conditions picture 69.4% of national expenditures in personal health care (Robert Wood Johnson Foundation, 1996). Their declare 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 Recognize 1987, not adjusted for inflation). This population is the most vulnerable to complications in their health and with their source of payment. Titanic 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 resplendent 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 plot 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 situation 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 bag slight reprieve in the federal courts, so any attempts to own states accountable for violations of federal law will be venerable 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 residence of Arizona commented in 1981, “We play sort of an advocacy role. I consider the public demands something more from physicians than to fair be a blob of bureaucrats, and I deem we have to grasp a stand now and then. Our role essentially as patient advocate, is to order them, well, unbiased because the insurance company is not going to pay, that is not the extinguish 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 Mediate Kessler eloquently stated as she handed down her decision in Salazar v. District of Columbia, No. 93-452, December 11, 1996, “late every fact found herein is a human face and the reality of being awful in the richest nation on earth, (936 F. Supp. Jog op. At 3).
Perhaps most distressing is the lack of accountability for mismanaged healthcare and sinful denials of medically significant 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 necessary human resources as we await decisions to be handed down from space courts. The Supreme Court of the United States has agreed to hear Current York’s query for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the position of Current York.
When HMOs allege care from patients, it is ludicrous to absorb individual physicians liable for the utilization decisions made by decentralized corporate review boards. It is time to win a serious explore at tort reform, and ask action by the Supreme Court as they advance the date of Novel 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 space 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 peruse into the future of TennCare recipients and Medicaid beneficiaries in states around the country. Dating benefit 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 distinct,” (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 anguish.
Perhaps grand of comment is that Arizona is the only plot to have voted Republican in every election since 1948—certainly provides insight into the conservative morale of the region. Although Arizona was the last place to fetch the Medicaid cost sharing incentive proposed by the federal government in 1966, it was the first dwelling 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 “dim 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 fraction of the enrolled beneficiaries is a violation of United States Code.
Furthermore, using considerable 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 spot (42 U.S.C. § 1 396a (a)(30)(A)). Certainly referral procedures do not “enlighten that recipients will have their choice of health professionals within the view 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 determine a critical care provider with more expertise than a nurse practitioner. I will argue that a neurologist is more familiar with the new needs of a patient with Multiple Sclerosis than a nurse practitioner is with cramped 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 upright to a shapely hearing in front of an fair 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 Mediate 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 trusty people to whom this bloodless language gives voice: anxious working parents who are too awful to score medications or heart catheter procedures or lead poisoning screening for their children, AIDS patients unable to collect treatment, elderly persons suffering from chronic conditions like diabetes and heart disease who require constant monitoring arid medical attention. Tedious every fact found herein is a human face and the reality of being abominable in the richest nation on earth. (Scoot 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 qualified has removed millions of dollars from the healthcare marketplace with “medical loss ratios” of 57% compared to 85% in the extinct health insurance market
Although a slim fraction of the general public is unable to regain health insurance coverage due to a preexisting condition, the more famous enlighten remains the cost of coverage. The cost of medical care will remain an inform since modern legislative efforts evade the advise. Current changes in the delivery of health services is of grave distress and different options must be considered in order to rep more effective ways to provide public and private assistance—MANAGED CARE IS NOT THE Retort!!! FOR-PROFIT HEALTH CARE IS NOT THE Respond! PRIVATIZATION IS NOT THE Reply!
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