Underwriting the Social Contract: Distributive Justice & Health Care Reform
The Quandary 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 broken-down 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 dreadful 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 trustworthy 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 positive 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 catch. 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 fetch within the original system. The rising costs of medical care contributed to the novel 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 wonderful.
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 old-fashioned 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 acquire 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 considerable anguish for those at risk for losing their health insurance. It does nothing to assist the uninsured obtain a decent health policy, and then provides no solution to the valuable jabber 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 pronounce of greatest distress to the citizens of this country: the cost of medical care. The Bill looks towards the states to create consumer protections and weakens the regulatory role of the federal government. The majority of the American public is unaware of the cherish footwork eager 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 principal 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 befriend 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 proper relate 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 fair 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 old in the utilization review process by tall insurance companies. Clearly, the most effective treatment for one patient may not be the best for another. The time required for utilization review may indicate 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 waste all in progressive legislation, however, in actuality it will only aid about 150,000 people.
Modern 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 novel 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 quiet subject to the utilization review process and access problems that stammer or delay medically vital treatment (Donelan, et. al., Hoffman & Rice, 1996).
Underwriting the Solidarity Principle
Used forms of insurance underwriting required that the contract explicitly residence which illness or services are not covered by the policy, in come. If the underwriter did not specifically place a sure 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 spy situation 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, gigantic 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 definite individuals to engage high-risk policies, the number of uninsured and underinsured Americans continues to grow exponentially (Durant, 1996).
More individuals are choosing not to rob 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 succor as “wildcards” since they allow insurers to enlighten 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 boom 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 ask 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 gargantuan 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 support 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 dilemma in distributive justice. Noble 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 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 belief polls from 1992 and 1994 (Blendon et. al., 1992; Blendon et. al., 1994). A unique observe by the American Medical Association found cost to be of paramount inconvenience to an overwhelming number of Americans (Donelan et. aI., 1996). Of the 40 million uninsured Americans, only 1% attributes their failure to regain health insurance coverage to their preexisting conditions. Among the uninsured, cost is cited as the indispensable 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 show 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 come for. Modern 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 effort about health care in this country, (1992, 1993, 1994, 1995, 1996).
Situation 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. (Modern York Times, 1996; The Recent 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 portray the human tragedy that lies beneath the web of the very worst of American capitalism: corporate greed.
Identifying Populations At-Risk
A contemplate by The Lewison Group in 1996 reveals insight into the private individual health insurance market. Clearly, individuals choosing to consume health insurance policies for several hundred dollars each month interrogate their health care needs and expenditures to exceed that amount Regardless of health position, a young healthy 25 year broken-down 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 Corrupt (based upon 1996 rates, new rates available from the Modern York Dwelling Insurance Department).
Since individual policies are not addressed in the Health Insurance Portability and Accountability Act of 1996 (HIPA), an individual policy with Blue Sinister Blue Shield of Tennessee excludes preexisting conditions for 24 months (enrollment booklet available upon inquire of). The vital 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 hold their indemnity style plans (Davis & Shoen, 1996; The Lewison Group, 1996).
Access to Medical Care
As routine practice, HMOs command or delay care for all services that are not outright medically primary. Growing numbers of individuals have suffered irreparable hurt, 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 grand evidence that individuals with chronic conditions receive sinful care in HMOs.
A four-year longitudinal inspect 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). Unusual statistics released in Washington, DC by the American Medical Association and the Robert Wood Johnson Foundation revealed the bid costs of individuals with chronic conditions fable for 75% of express 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 content 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 hiss medical expenditures, which means the millions of dollars being made by for-profit insurance companies are not being circulated into the economy to succor 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 customary to fatten the pockets of CEO’s and majority stockholders (Healthline, 1996).
Based upon a current describe from the Robert Wood Johnson Foundation, the advise costs for persons with chronic conditions narrate 69.4% of national expenditures in personal health care (Robert Wood Johnson Foundation, 1996). Their announce 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 See 1987, not adjusted for inflation). This population is the most vulnerable to complications in their health and with their source of payment. Grand 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 ravishing 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 pickle 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 place 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 set 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 regain tiny reprieve in the federal courts, so any attempts to bear states accountable for violations of federal law will be ragged 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 judge the public demands something more from physicians than to impartial be a blob of bureaucrats, and I reflect we have to grasp a stand now and then. Our role essentially as patient advocate, is to inform them, well, objective because the insurance company is not going to pay, that is not the kill 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 Contemplate 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 abominable in the richest nation on earth, (936 F. Supp. Swagger op. At 3).
Perhaps most distressing is the lack of accountability for mismanaged healthcare and bad 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 primary human resources as we await decisions to be handed down from place courts. The Supreme Court of the United States has agreed to hear Unusual York’s expect for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the station of Unusual York.
When HMOs state care from patients, it is ludicrous to maintain individual physicians liable for the utilization decisions made by decentralized corporate review boards. It is time to buy a serious search for at tort reform, and question action by the Supreme Court as they arrive the date of Unique 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 status 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 distress due to the systematic denial of medical care grows larger each day.
The history of Medicaid Managed Care does not provide a very optimistic perceive into the future of TennCare recipients and Medicaid beneficiaries in states around the country. Dating attend 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 grief.
Perhaps kindly of comment is that Arizona is the only position to have voted Republican in every election since 1948—certainly provides insight into the conservative morale of the place. Although Arizona was the last plot to glean 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 space strategic barriers to access medical treatment and services in Health Maintenance Organizations (HMOs). Pre-certification requirements are strategic barriers incorporated into the “shadowy box” of utilization review that institutionalizes exclusionary waiting periods and routine denials of medically important 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 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 place (42 U.S.C. § 1 396a (a)(30)(A)). Certainly referral procedures do not “thunder that recipients will have their choice of health professionals within the thought 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 settle a well-known care provider with more expertise than a nurse practitioner. I will argue that a neurologist is more familiar with the unusual 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 suitable to a shapely 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 Think 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, unpleasant, 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 true people to whom this bloodless language gives voice: anxious working parents who are too unpleasant to gain medications or heart catheter procedures or lead poisoning screening for their children, AIDS patients unable to salvage treatment, elderly persons suffering from chronic conditions like diabetes and heart disease who require constant monitoring arid medical attention. Slack every fact found herein is a human face and the reality of being awful in the richest nation on earth. (Tear 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 pleasant has removed millions of dollars from the healthcare marketplace with “medical loss ratios” of 57% compared to 85% in the broken-down health insurance market
Although a slim part of the general public is unable to procure health insurance coverage due to a preexisting condition, the more distinguished mutter remains the cost of coverage. The cost of medical care will remain an philosophize since novel legislative efforts evade the say. Current changes in the delivery of health services is of grave grief and different options must be considered in order to gain more effective ways to provide public and private assistance—MANAGED CARE IS NOT THE Reply!!! FOR-PROFIT HEALTH CARE IS NOT THE Retort! PRIVATIZATION IS NOT THE Respond!
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Underwriting the Social Contract: Distributive Justice & Health Care Reform
The Spot 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 feeble 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 cut 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 first-rate 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.
New trend towards localized government leaves individuals without a financial safety rep. This is the least efficient manner to handle health care costs, and evades the premise that medical care is a natural moral in a civilized society. Few Americans feel salvage within the novel system. The rising costs of medical care contributed to the fresh market changes in both the administration and delivery of health services. The financial incentive to shroud only the healthiest individuals ignores the fact that medical care is a social wonderful.
Health Insurance Portability Act of 1996
Two years after the Clinton Health Concept 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 serve an estimated 150,000 Americans earn 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 peril for those at risk for losing their health insurance. It does nothing to assist the uninsured procure a decent health policy, and then provides no solution to the significant narrate 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 lisp of greatest trouble to the citizens of this country: the cost of medical care. The Bill looks towards the states to fabricate consumer protections and weakens the regulatory role of the federal government. The majority of the American public is unaware of the worship 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 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 attend 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 upright bellow 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 objective 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 traditional in the utilization review process by great 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 slay all in progressive legislation, however, in actuality it will only relieve about 150,000 people.
Modern 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 station 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 collected subject to the utilization review process and access problems that allege or delay medically critical treatment (Donelan, et. al., Hoffman & Rice, 1996).
Underwriting the Solidarity Principle
Obsolete forms of insurance underwriting required that the contract explicitly situation which illness or services are not covered by the policy, in reach. If the underwriter did not specifically spot a obvious 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 stare station 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, tremendous insurance companies began including sexual orientation as a high-risk category, by using actuarial sound criteria. Such criteria concluded that ecstatic 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 spend, insurance companies are able to offer rock bottom prices for young, healthy individuals. By excluding preexisting conditions and requiring obvious individuals to engage high-risk policies, the number of uninsured and underinsured Americans continues to grow exponentially (Durant, 1996).
More individuals are choosing not to pick 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 relieve as “wildcards” since they allow insurers to lisp 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 enlighten 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 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 mountainous 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 serve 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. Noble health is care is primary 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 view polls from 1992 and 1994 (Blendon et. al., 1992; Blendon et. al., 1994). A modern discover by the American Medical Association found cost to be of paramount pain to an overwhelming number of Americans (Donelan et. aI., 1996). Of the 40 million uninsured Americans, only 1% attributes their failure to accumulate health insurance coverage to their preexisting conditions. Among the uninsured, cost is cited as the notable 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 exhibit 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. Unusual 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).
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. (Unique York Times, 1996; The Current York Daily News, 1996; Long Island Newsday, 1996; LA Times, 1996; Picayne Times, 1996; Columbia Spectator, 1996; Columbia University Portray, 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 recount the human tragedy that lies beneath the web of the very worst of American capitalism: corporate greed.
Identifying Populations At-Risk
A look by The Lewison Group in 1996 reveals insight into the private individual health insurance market. Clearly, individuals choosing to assume health insurance policies for several hundred dollars each month query their health care needs and expenditures to exceed that amount Regardless of health region, a young healthy 25 year worn who purchases an individual health insurance policy can examine to pay well over $300.00 monthly for a health insurance policy with Empire Blue Shield Blue Spoiled (based upon 1996 rates, unique rates available from the Fresh York Place Insurance Department).
Since individual policies are not addressed in the Health Insurance Portability and Accountability Act of 1996 (HIPA), an individual policy with Blue Inferior Blue Shield of Tennessee excludes preexisting conditions for 24 months (enrollment booklet available upon demand). The distinguished 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 withhold their indemnity style plans (Davis & Shoen, 1996; The Lewison Group, 1996).
Access to Medical Care
As routine practice, HMOs issue or delay care for all services that are not outright medically significant. Growing numbers of individuals have suffered irreparable distress, and many have died awaiting approval from their HMO’s (The Recent 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 titanic evidence that individuals with chronic conditions receive gross care in HMOs.
A four-year longitudinal observe 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). Fresh statistics released in Washington, DC by the American Medical Association and the Robert Wood Johnson Foundation revealed the command costs of individuals with chronic conditions tale for 75% of sigh 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 convey 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 mumble medical expenditures, which means the millions of dollars being made by for-profit insurance companies are not being circulated into the economy to back 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 feeble to fatten the pockets of CEO’s and majority stockholders (Healthline, 1996).
Based upon a fresh portray from the Robert Wood Johnson Foundation, the roar costs for persons with chronic conditions report 69.4% of national expenditures in personal health care (Robert Wood Johnson Foundation, 1996). Their sigh 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. Sizable 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 spot 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 place 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 derive exiguous reprieve in the federal courts, so any attempts to beget states accountable for violations of federal law will be musty 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 reflect the public demands something more from physicians than to impartial be a blob of bureaucrats, and I judge we have to occupy a stand now and then. Our role essentially as patient advocate, is to roar 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 Mediate Kessler eloquently stated as she handed down her decision in Salazar v. District of Columbia, No. 93-452, December 11, 1996, “slack every fact found herein is a human face and the reality of being abominable in the richest nation on earth, (936 F. Supp. Hurry op. At 3).
Perhaps most distressing is the lack of accountability for mismanaged healthcare and bad denials of medically principal 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 vital human resources as we await decisions to be handed down from region courts. The Supreme Court of the United States has agreed to hear Novel York’s examine for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the position of Unusual York.
When HMOs voice care from patients, it is ludicrous to occupy individual physicians liable for the utilization decisions made by decentralized corporate review boards. It is time to purchase a serious inspect at tort reform, and ask action by the Supreme Court as they advance the date of Recent 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 distress due to the systematic denial of medical care grows larger each day.
The history of Medicaid Managed Care does not provide a very optimistic recognize 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 pain.
Perhaps satisfactory 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 station. Although Arizona was the last residence to come by the Medicaid cost sharing incentive proposed by the federal government in 1966, it was the first residence to force its medically indigent population into managed care in 1981.
Violating Federal Law
Rigid pre-certification requirements and nonspecific utilization review procedures situation 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 critical 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 situation (42 U.S.C. § 1 396a (a)(30)(A)). Certainly referral procedures do not “command 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 resolve a essential care provider with more expertise than a nurse practitioner. I will argue that a neurologist is more familiar with the recent needs of a patient with Multiple Sclerosis than a nurse practitioner is with runt 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 apt to a pleasing hearing in front of an unbiased 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 exact people to whom this bloodless language gives voice: anxious working parents who are too unpleasant to net medications or heart catheter procedures or lead poisoning screening for their children, AIDS patients unable to acquire treatment, elderly persons suffering from chronic conditions like diabetes and heart disease who require constant monitoring arid medical attention. Unhurried every fact found herein is a human face and the reality of being unpleasant in the richest nation on earth. (Glide 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 suited has removed millions of dollars from the healthcare marketplace with “medical loss ratios” of 57% compared to 85% in the aged health insurance market
Although a slim fragment of the general public is unable to secure health insurance coverage due to a preexisting condition, the more important protest remains the cost of coverage. The cost of medical care will remain an voice since unique legislative efforts evade the roar. Modern changes in the delivery of health services is of grave exertion and different options must be considered in order to regain more effective ways to provide public and private assistance—MANAGED CARE IS NOT THE Acknowledge!!! FOR-PROFIT HEALTH CARE IS NOT THE Retort! PRIVATIZATION IS NOT THE Respond!
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