Underwriting the Social Contract: Distributive Justice & Health Care Reform
The Scrape 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 crop financial risk, health insurance companies have restricted enrollment to individuals in unpleasant 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 safe 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 glean. 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 gather within the modern system. The rising costs of medical care contributed to the unique 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 pleasant.
Health Insurance Portability Act of 1996
Two years after the Clinton Health Thought was defeated in Congress, Senator Ted Kennedy and Nancy Kassebaum introduced the Kennedy-Kassebaum Bill in response to growing concerns about selective enrollment procedures passe 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 succor an estimated 150,000 Americans score 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 well-known wretchedness for those at risk for losing their health insurance. It does nothing to serve the uninsured come by a decent health policy, and then provides no solution to the important insist at hand— cost
Since Kennedy-Kassebaum does nothing to control the cost of health insurance and medical care in America, the Bill fails to answer to the vow of greatest trouble to the citizens of this country: the cost of medical care. The Bill looks towards the states to get consumer protections and weakens the regulatory role of the federal government. The majority of the American public is unaware of the love 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 essential 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 encourage 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 fair 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 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 customary in the utilization review process by huge 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 destroy all in progressive legislation, however, in actuality it will only wait on 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 unique health state 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 calm subject to the utilization review process and access problems that explain or delay medically indispensable treatment (Donelan, et. al., Hoffman & Rice, 1996).
Underwriting the Solidarity Principle
Mature forms of insurance underwriting required that the contract explicitly dwelling which illness or services are not covered by the policy, in come. If the underwriter did not specifically space a determined condition in the contract, the insurer was held to the terms of the contract and required to pay for services utilized by the policyholder (Stone, 1994, as cited in Durant, 1996).
Increasing numbers of for-profit and non-profit insurance companies began to control costs by refusing to insure individuals who they felt would consume more services. Insurers began to require health search for residence 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, great insurance companies began including sexual orientation as a high-risk category, by using actuarial sound criteria. Such criteria concluded that joyful men were a higher risk for contracting AIDS virus and refused to write policies for anyone believed to be homosexual, (Stone, 1994 as cited in Durant, 1996).
By limiting enrollment to the healthiest members of society, selective enrollment undermines the solidarity principle of health insurance (Davis & Shoen, 1996; Snow, 1996; Stone, 1994). By eliminating those who were suspect of using more services than their healthier counterparts consume, insurance companies are able to offer rock bottom prices for young, healthy individuals. By excluding preexisting conditions and requiring positive individuals to capture high-risk policies, the number of uninsured and underinsured Americans continues to grow exponentially (Durant, 1996).
More individuals are choosing not to grasp 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 voice 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 deliver 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 examine 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 astronomical 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 befriend 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. Generous health is care is principal 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 notion polls from 1992 and 1994 (Blendon et. al., 1992; Blendon et. al., 1994). A modern spy by the American Medical Association found cost to be of paramount effort to an overwhelming number of Americans (Donelan et. aI., 1996). Of the 40 million uninsured Americans, only 1% attributes their failure to get health insurance coverage to their preexisting conditions. Among the uninsured, cost is cited as the critical 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 view polls display 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 near for. Unique 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).
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. (Modern York Times, 1996; The Unusual York Daily News, 1996; Long Island Newsday, 1996; LA Times, 1996; Picayne Times, 1996; Columbia Spectator, 1996; Columbia University Picture, 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 sight by The Lewison Group in 1996 reveals insight into the private individual health insurance market. Clearly, individuals choosing to buy health insurance policies for several hundred dollars each month ask their health care needs and expenditures to exceed that amount Regardless of health state, a young healthy 25 year extinct who purchases an individual health insurance policy can inquire to pay well over $300.00 monthly for a health insurance policy with Empire Blue Shield Blue Heinous (based upon 1996 rates, novel rates available from the Recent York Set Insurance Department).
Since individual policies are not addressed in the Health Insurance Portability and Accountability Act of 1996 (HIPA), an individual policy with Blue Improper Blue Shield of Tennessee excludes preexisting conditions for 24 months (enrollment booklet available upon demand). The indispensable 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 recount or delay care for all services that are not outright medically valuable. Growing numbers of individuals have suffered irreparable pain, 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 mountainous evidence that individuals with chronic conditions receive deplorable care in HMOs.
A four-year longitudinal inspect 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). Novel statistics released in Washington, DC by the American Medical Association and the Robert Wood Johnson Foundation revealed the impart costs of individuals with chronic conditions narrative for 75% of thunder 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 dispute 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 yell 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 old to fatten the pockets of CEO’s and majority stockholders (Healthline, 1996).
Based upon a novel represent from the Robert Wood Johnson Foundation, the bid costs for persons with chronic conditions characterize 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 Study 1987, not adjusted for inflation). This population is the most vulnerable to complications in their health and with their source of payment. Immense 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 splendid 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 status 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 position 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 pick up shrimp reprieve in the federal courts, so any attempts to enjoy states accountable for violations of federal law will be broken-down 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 station of Arizona commented in 1981, “We play sort of an advocacy role. I contemplate the public demands something more from physicians than to honest be a blob of bureaucrats, and I contemplate we have to select a stand now and then. Our role essentially as patient advocate, is to enlighten them, well, fair 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 Reflect Kessler eloquently stated as she handed down her decision in Salazar v. District of Columbia, No. 93-452, December 11, 1996, “gradual every fact found herein is a human face and the reality of being unpleasant in the richest nation on earth, (936 F. Supp. Slither op. At 3).
Perhaps most distressing is the lack of accountability for mismanaged healthcare and wicked denials of medically famous treatment. HMOs claim immunity under ERISA, and leaving individuals without recourse in a sea contractual language and lengthy court calendars. It is evident that individuals protected under the Medicaid Act are not fundamentally different from other populations entrapped in the maze of managed care. They are simply those who have “had their day in court.”
Due Process Protections
Since all Americans are theoretically entitled to due process protections under the constitution of the United States, it seems the federal courts are long overdue for making such a public statement. We are wasting precious time and losing millions in indispensable human resources as we await decisions to be handed down from plot courts. The Supreme Court of the United States has agreed to hear Unusual York’s seek information from for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the area of Fresh York.
When HMOs recount care from patients, it is ludicrous to acquire individual physicians liable for the utilization decisions made by decentralized corporate review boards. It is time to select a serious stare at tort reform, and inquire action by the Supreme Court as they come 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 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 observe into the future of TennCare recipients and Medicaid beneficiaries in states around the country. Dating succor 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 certain,” (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 danger.
Perhaps valid of comment is that Arizona is the only spot to have voted Republican in every election since 1948—certainly provides insight into the conservative morale of the spot. Although Arizona was the last residence to glean the Medicaid cost sharing incentive proposed by the federal government in 1966, it was the first station to force its medically indigent population into managed care in 1981.
Violating Federal Law
Rigid pre-certification requirements and nonspecific utilization review procedures plot 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 notable 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 principal 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 dwelling (42 U.S.C. § 1 396a (a)(30)(A)). Certainly referral procedures do not “divulge that recipients will have their choice of health professionals within the understanding to the extent possible and appropriate,” (42 U.S.C. § 434.29). Under this provision, it seems that any individual, especially those with chronic health conditions or disabilities should be allowed to decide a necessary care provider with more expertise than a nurse practitioner. I will argue that a neurologist is more familiar with the original needs of a patient with Multiple Sclerosis than a nurse practitioner is with dinky 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 moral to a heavenly hearing in front of an honest 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 Contemplate Kessler told her courtroom. Her words are certainly words I will not forget—certainly worth being quoted at length:
“This case is about people—children and adults who are sick, dreadful, and vulnerable—for whom life, in the memorable words of poet Langston Hughes, “ain’t been no crystal stair”. It is written in the dry and bloodless language of “the Iaw”—statistics, acronyms of agencies and bureaucratic entities, Supreme Court case names and quotes, official governmental reports, periodicity tables, etc. But let there be no forgetting the dependable people to whom this bloodless language gives voice: anxious working parents who are too unpleasant to salvage medications or heart catheter procedures or lead poisoning screening for their children, AIDS patients unable to bag 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 unpleasant in the richest nation on earth. (Wander 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 faded health insurance market
Although a slim allotment of the general public is unable to net health insurance coverage due to a preexisting condition, the more considerable dispute remains the cost of coverage. The cost of medical care will remain an relate since unusual legislative efforts evade the recount. Unusual changes in the delivery of health services is of grave exertion and different options must be considered in order to procure more effective ways to provide public and private assistance—MANAGED CARE IS NOT THE Reply!!! FOR-PROFIT HEALTH CARE IS NOT THE Reply! PRIVATIZATION IS NOT THE Respond!
References
Blumstein, J. F. (1996). Health care reform and competing visions of medical care: Antitrust and place provider cooperative legislation. Cornell Law Review,79,1459-1506.
Blumstein, J. F. (1996). The fraud and abuse statute in an evolving health care market Life in the health care speakeasy. American Journal of Law and Medicine,22(2), 205-231.
Bunis, D. (1996, July 16). Sweeping changes for health care: What it means to you. Long Island Newsday, pp. A6, A53.
Chartland, S. (1996, April 28). The changing game of health insurance. The Original York Times [On-line. Available: http://www.ny€mes~com/
College of Physicians and Surgeons at Columbia-Presbyterian Medical Center Office of Public Relations. (1996, July 25) Press Release: Recent York's Ivy League Medical Schools converse first of its kind affiance.
Clymer, A. (1996, August 1). Accord reached on expanding worker's health benefits. The Current York Times [On-line] Available: http://www.nytimes.com/yr/mo/day/pOlitic5/healthbffl.htmI
Consumer Reports. (1996, May 31). Children and health care.
Davis, K., & Shoen, (1996, March). Health services research and the changing health care system. Current York: The Commonwealth Fund. Available: http://www.cmwf.org
Donelan, K., Blendon, R. J. Hill, C.A., Hoffman, C., Rowland, D., Frankel, M., Altman, D. (1996). Whatever happened to the health insurance crisis in the United States? Journal of the American Medical Association,276(16), 1346-1350.
Durant, E.D. (1996). The Original York Health Reform Act of 1996: Costs of Exclusion. (Unpublished).
Employee Abet Research Institute. (1992). Sources of health insurance and characteristics of the uninsured. (Remark Brief No. 123). Washington, DC. Available: http://www.ebri.org
Families USA (1996, July). HMO Consumers at risk: States to the rescue. Washington, DC: Families USA. Available: http://epn.org.families/farisk.html
Families USA (1996, June 7). New York managed care legislation: A model for other states. Washington, DC: Families USA. Available: http://epn.org/families/fastat.html
Families USA (1996, August). Kassebaum-Kennedy health insurance bill clears congress: Medicaid Saving Accounts little to demonstration program. Washington, DC: Families USA. Available: http://epn.org/families/fakeka.html
Fein, E. B. (1996, July 5). For-profit hospitals: Once unthinkable, now probably inevitable. The Unusual York Times, [On-line]. Available: http://www.nytimes.com
Freudenheim, M. (1996, July 16). Grading becomes stricter on health plans. The Fresh York Times. [On-line]. Available: http://www.nytimes.com/sectionS/bUSiness
Health Care Portability and Accountability Act of 1996, Pub. L. No. 104-191 (1996).
Hoffman, C., Rice, D.R., & Sung, H.Y., (1996). Persons with chronic conditions: Their prevalence and costs. Journal of the American Medical Association,276,1473-1479.
Holusha, J. (1996, August18). For doctors togetherness is the novel design of life. The Modern York Times [On-line]. Available: http://www.nytimes.com/Cp960818.htfl1l
Levinson, M. (1996, June 26). As Blue Wrong and Blue Shield head into the for-profit sector, it is helping to open the biggest gold hasten since Sutter’s Mill. U.S.New [On-line]. Available: http:/ / www.usnews.com/
Levy, C. J. (1996, July 2). Unique era in Recent York hospital-rate belief. The Unusual York Times, pp. Al.
Malpractice law evolves under managed care. Paper presented at the conference, Emerging Liability Issues in Managed Care, sponsored by the Robert Wood Johnson Foundation’s Improving Malpractice Prevention and Compensation Systems (IMPACS) program, October, 1995.
Market competition and the health care safety fetch. States of Health, (December, 1996) Washington, DC: Families USA. Available: http://epn.org/families/safeflet/html
Med-Access Search: Hospital Database. Available: http://medaccess.com/cgi/Hospital_basic.eXe
Metcalf, E. (1996, September 6). Columbia and Cornell understanding alliance—2,800 physicians strong.. Columbia University Spectator, p.1.
Metcalf, E. (1996, September 27). Columbia/Cornell MD’s Ally. Columbia University Narrate, p. 1.
Nasr, H. (1996, July 31). Major university hospitals to merge. Columbia University Spectator, pp. 1,8.
Fresh York Health Reform Act of 1996, NY AB 11330.
Pear, R. (1996, May 26). Two trends collide: The rise in depart and of local HMOs. The Recent York Times [On-line]. Available: http://www.nytimes.com
Perrin, E. C., Newacheck, P., Pless, B. I. Drotar, D., Gortmeaker, Steven, L., Leventhal, I., Perrin, J.M., Stein, R.E., Walker, D.E. Weitzman, M. (1993). Issues eager in the definition and classification of chronic health conditions. Pediatrics, 91(4), 787-793.
Robert Wood Johnson Foundation (December 1995). HealthTracking: HMOs and US health care. Available: http://rwjf.org
Robert Wood Johnson Foundation (February 1995). Market consolidation, antitrust, and public policy in the health care industry: Agenda for future research. Prepared for the council on the economic impact of health care reform (item: HTO1).
Robert Wood Johnson Foundation (December 1995). Health Tracking: HMOs and US health care. Available: http://rwjf.org
Robert Wood Johnson Foundation (February 1995). Market consolidation, antitrust, and public policy in the health care industry: Agenda for future research. Prepared for the council on the economic impact of health care reform (item: HTO1).Robinson, R. (1993). Economic evaluation in health care: Cost-effectiveness analysis. [Education & Debate]. The British Medical Journal,307(6907), 793-795.
Robinson, R. (1993). Economic evaluation in health care: Cost-effectiveness analysis. [Education & Debate]. The British Medical Journal,307(6909), 924-926.
Rosenthal, E. (1996, July 2). Two more hospitals run to join forces: Beth Israel-Long Island Jewish Merger to do far-flung empire. The Modern York Times, p. B3.
Rosenthal, E. (1996, July 15). Patients say NY 1-IMOs don’t deal well with complex illnesses. The Recent York Times, p. Al.
Schiff, G. S. (1996, March 16). Managed care issues. Physicians for a National Health Thought. Available: pnhp@aol.com -
Selby, J. V., Fireman, B. H., & Swain, B.E. (1996). Attain of a copayment on employ of the emergency department in a health maintenance organization. New England Journal of Medicine, 334,635-641.
Shaw, T. (1996, March 25). Dole’s poor medicine: health reform opinion would raise costs, injure quality. USAToday, [On-line]. Distributed by the National Center for Policy Analysis.
Smolowe, J., Perman, S., & Van Tassel,J. (1996, April 15) A healthy merger? A broad deal makes Aetna the country’s largest health-care company. Time Magazine,14(16).
Spragins, E. (1996, September 24). Special Portray America’s best 1-IMOs: Rating the top managed care companies. Newsweek, pp.58-63.
Stone, D. A. (Monroe, J. A. & Beilcin, C. S. eds. 1994). The struggle for the soul of health insurance. The Politics of Health Care Reform,27-56.
Taylor, H. (1996, July 16). Health care capitalism remakes a city’s health system. The Albany Times [On-line]
Toim L (1996 July 31) Local 2110 loses its benefits Columbia University Spectator, pp 1-5
Van Duzer, K., & Nasr, H. (1996,July 31). Nurses reject final hospital’s offer, strike possible. Columbia University Spectator, pp. 1,8.
Ware, J.E., Bayliss, M.S., Rogers,W.H., Kosinski, M., Tarlov, A.R. (1996). Differences in 4-year health outcomes for elderly, awful, and chronically if patients treated in HMO and Fee-for-Service systems: Results perform a medical outcomes perceive. Journal of the American Medical Association. L 1039-1047.
Williams, R. M. (1996). The cost of visits to emergency departments. New England Journal of Medicine, 334 642-646
Wines, M., & Pear, R. (1996, July 30). The President finds earn advantage from failure of health-care pains. The Unusual York Times [On-line]. Available: http://www.nytimes.cOm/web/dOcsroot/library/Politics/0730editon.html
Underwriting the Social Contract: Distributive Justice & Health Care Reform
The Scrape Statement
As health care costs climbed exponentially in the 1980’s, so did the cost of health insurance plans. As a result, employers began to enroll their employees in managed care organizations, and many Americans were forced to leave their old-fashioned indemnity type plans. With the advent of the health maintenance organization, there is a financial incentive for the underutilization of care. (Blumstein, 1996; Davis & Shoen, 1996).
In order to cut 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 good 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.
Novel trend towards localized government leaves individuals without a financial safety secure. 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 procure within the original system. The rising costs of medical care contributed to the modern market changes in both the administration and delivery of health services. The financial incentive to camouflage only the healthiest individuals ignores the fact that medical care is a social proper.
Health Insurance Portability Act of 1996
Two years after the Clinton Health Conception was defeated in Congress, Senator Ted Kennedy and Nancy Kassebaum introduced the Kennedy-Kassebaum Bill in response to growing concerns about selective enrollment procedures stale 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 attend an estimated 150,000 Americans get 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 well-known wretchedness for those at risk for losing their health insurance. It does nothing to support the uninsured bag a decent health policy, and then provides no solution to the famous squawk 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 mutter of greatest danger 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 treasure footwork alive to with this legislation, and the demographics of the population it is intended to protect. In order to assess the utility of this Bill, it is necessary to identify the populations at risk for loosing health insurance coverage and the underinsured.
Kassebaum-Kennedy focuses on a slim 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 support from this legislation. The Health Insurance Portability and Accountability Act of 1996 is really nothing more than smoke and mirrors since it fails to address the fair disclose 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 fervent in treatment studies. Each condition requires individualized treatment that cannot be based upon the simple economic/cost-benefit analysis venerable in the utilization review process by enormous insurance companies. Clearly, the most effective treatment for one patient may not be the best for another. The time required for utilization review may explain 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 befriend about 150,000 people.
Novel studies have found that the majority of the uninsured population simply cannot afford to pay the premiums (Donelan et. al., 1996; Hoffman & Rice, 1996). According to their data, only 1% of the Uninsured population is due to new health area 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 drawl or delay medically important treatment (Donelan, et. al., Hoffman & Rice, 1996).
Underwriting the Solidarity Principle
Veteran forms of insurance underwriting required that the contract explicitly spot which illness or services are not covered by the policy, in arrive. If the underwriter did not specifically status 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 employ more services. Insurers began to require health glimpse 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, colossal insurance companies began including sexual orientation as a high-risk category, by using actuarial sound criteria. Such criteria concluded that delighted 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 exhaust, insurance companies are able to offer rock bottom prices for young, healthy individuals. By excluding preexisting conditions and requiring distinct individuals to rob high-risk policies, the number of uninsured and underinsured Americans continues to grow exponentially (Durant, 1996).
More individuals are choosing not to bewitch insurance simply because they cannot afford it. Even among those with employer based health coverage, the policies frequently exclude coverage for long-term illness or care of chronic conditions (MSNBC News Forum, 1996). Without a standard definition of preexisting conditions, these clauses befriend as “wildcards” since they allow insurers to scream 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 stutter 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 question 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 stout 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 back 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. Superb health is care is indispensable 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 modern ogle 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 catch 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 view polls show the legitimate role and public desire for government regulation of the health care industry. It has become distinct 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. Original models of distributive justice emphasize public consensus as a legitimate role for government intervention. According to a number of studies by Blendon and his colleagues, the public has reported an overwhelming general worry about health care in this country, (1992, 1993, 1994, 1995, 1996).
Status 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 Current 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 describe the human tragedy that lies beneath the web of the very worst of American capitalism: corporate greed.
Identifying Populations At-Risk
A gawk by The Lewison Group in 1996 reveals insight into the private individual health insurance market. Clearly, individuals choosing to catch health insurance policies for several hundred dollars each month demand their health care needs and expenditures to exceed that amount Regardless of health set, a young healthy 25 year ancient who purchases an individual health insurance policy can inquire of to pay well over $300.00 monthly for a health insurance policy with Empire Blue Shield Blue Irascible (based upon 1996 rates, unusual rates available from the Novel 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 Contaminated Blue Shield of Tennessee excludes preexisting conditions for 24 months (enrollment booklet available upon expect). 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 hold their indemnity style plans (Davis & Shoen, 1996; The Lewison Group, 1996).
Access to Medical Care
As routine practice, HMOs divulge or delay care for all services that are not outright medically essential. Growing numbers of individuals have suffered irreparable damage, and many have died awaiting approval from their HMO’s (The Unusual York Times, 1996; Long Island Newsday, 1996; The Tennessean, 1996; Healthline, 1996). It is hardly a secret that HMOs have fallen short of their promise to provide comprehensive health care for the “whole” individual by emphasizing preventative medicine, using medical management to coordinate care. There is ample evidence that individuals with chronic conditions receive rotten care in HMOs.
A four-year longitudinal inspect of medical outcomes found that the elderly, the unpleasant, 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 hiss costs of individuals with chronic conditions record for 75% of relate 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 snort 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 assure medical expenditures, which means the millions of dollars being made by for-profit insurance companies are not being circulated into the economy to befriend in public health costs care. The industry made a 14.8% profit in the 3rd quarter of 1996, however these medical dollars were removed from health care and weak to fatten the pockets of CEO’s and majority stockholders (Healthline, 1996).
Based upon a current recount from the Robert Wood Johnson Foundation, the negate costs for persons with chronic conditions describe 69.4% of national expenditures in personal health care (Robert Wood Johnson Foundation, 1996). Their deliver 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 Inspect 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 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 status 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 status 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 come by petite reprieve in the federal courts, so any attempts to beget states accountable for violations of federal law will be used 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 region of Arizona commented in 1981, “We play sort of an advocacy role. I mediate the public demands something more from physicians than to honest be a blob of bureaucrats, and I deem we have to engage a stand now and then. Our role essentially as patient advocate, is to drawl them, well, objective because the insurance company is not going to pay, that is not the destroy 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 Reflect Kessler eloquently stated as she handed down her decision in Salazar v. District of Columbia, No. 93-452, December 11, 1996, “slow every fact found herein is a human face and the reality of being dreadful in the richest nation on earth, (936 F. Supp. Scoot op. At 3).
Perhaps most distressing is the lack of accountability for mismanaged healthcare and evil 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 considerable human resources as we await decisions to be handed down from space courts. The Supreme Court of the United States has agreed to hear Modern York’s interrogate for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the set of Unusual York.
When HMOs mutter 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 seize a serious leer at tort reform, and inquire action by the Supreme Court as they near 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 location 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 hurt due to the systematic denial of medical care grows larger each day.
The history of Medicaid Managed Care does not provide a very optimistic see into the future of TennCare recipients and Medicaid beneficiaries in states around the country. Dating abet to the implementation of the Arizona Health Care Cost Containment System (AHCCCS) in 1981, there are documented cases where “people reportedly died for lack of medical treatment before their eligibility was positive,” (Varley, as cited in Gutman & Thompson, I 996). This leaves me to wonder why the states continue to enroll their most vulnerable populations into a system of managed care that has proven to be a pains.
Perhaps profitable of comment is that Arizona is the only station to have voted Republican in every election since 1948—certainly provides insight into the conservative morale of the place. Although Arizona was the last spot to net the Medicaid cost sharing incentive proposed by the federal government in 1966, it was the first station to force its medically indigent population into managed care in 1981.
Violating Federal Law
Rigid pre-certification requirements and nonspecific utilization review procedures plot strategic barriers to access medical treatment and services in Health Maintenance Organizations (HMOs). Pre-certification requirements are strategic barriers incorporated into the “sunless box” of utilization review that institutionalizes exclusionary waiting periods and routine denials of medically famous 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 critical 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 set (42 U.S.C. § 1 396a (a)(30)(A)). Certainly referral procedures do not “mutter 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 vital 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 microscopic 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 lawful to a blooming hearing in front of an honest independent Medical Review Unit (MRU). Furthermore, the Medicaid Act clearly states that medical services for a Medicaid beneficiary may not be terminated until the said beneficiary receives such a hearing
Conclusion
The country as a whole must realize what Deem Kessler told her courtroom. Her words are certainly words I will not forget—certainly worth being quoted at length:
“This case is about people—children and adults who are sick, awful, and vulnerable—for whom life, in the memorable words of poet Langston Hughes, “ain’t been no crystal stair”. It is written in the dry and bloodless language of “the Iaw”—statistics, acronyms of agencies and bureaucratic entities, Supreme Court case names and quotes, official governmental reports, periodicity tables, etc. But let there be no forgetting the right people to whom this bloodless language gives voice: anxious working parents who are too unpleasant to accumulate medications or heart catheter procedures or lead poisoning screening for their children, AIDS patients unable to win treatment, elderly persons suffering from chronic conditions like diabetes and heart disease who require constant monitoring arid medical attention. Slow every fact found herein is a human face and the reality of being awful in the richest nation on earth. (Fling 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 profitable has removed millions of dollars from the healthcare marketplace with “medical loss ratios” of 57% compared to 85% in the former health insurance market
Although a slim fraction of the general public is unable to salvage health insurance coverage due to a preexisting condition, the more necessary exclaim remains the cost of coverage. The cost of medical care will remain an bid since unique legislative efforts evade the divulge. Current changes in the delivery of health services is of grave misfortune and different options must be considered in order to score 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!
References
Blumstein, J. F. (1996). Health care reform and competing visions of medical care: Antitrust and area provider cooperative legislation. Cornell Law Review,79,1459-1506.
Blumstein, J. F. (1996). The fraud and abuse statute in an evolving health care market Life in the health care speakeasy. American Journal of Law and Medicine,22(2), 205-231.
Bunis, D. (1996, July 16). Sweeping changes for health care: What it means to you. Long Island Newsday, pp. A6, A53.
Chartland, S. (1996, April 28). The changing game of health insurance. The Novel York Times [On-line. Available: http://www.ny€mes~com/
College of Physicians and Surgeons at Columbia-Presbyterian Medical Center Office of Public Relations. (1996, July 25) Press Release: Original York's Ivy League Medical Schools tell first of its kind affiance.
Clymer, A. (1996, August 1). Accord reached on expanding worker's health benefits. The Current York Times [On-line] Available: http://www.nytimes.com/yr/mo/day/pOlitic5/healthbffl.htmI
Consumer Reports. (1996, May 31). Children and health care.
Davis, K., & Shoen, (1996, March). Health services research and the changing health care system. Modern York: The Commonwealth Fund. Available: http://www.cmwf.org
Donelan, K., Blendon, R. J. Hill, C.A., Hoffman, C., Rowland, D., Frankel, M., Altman, D. (1996). Whatever happened to the health insurance crisis in the United States? Journal of the American Medical Association,276(16), 1346-1350.
Durant, E.D. (1996). The Unusual York Health Reform Act of 1996: Costs of Exclusion. (Unpublished).
Employee Encourage Research Institute. (1992). Sources of health insurance and characteristics of the uninsured. (Suppose Brief No. 123). Washington, DC. Available: http://www.ebri.org
Families USA (1996, July). HMO Consumers at risk: States to the rescue. Washington, DC: Families USA. Available: http://epn.org.families/farisk.html
Families USA (1996, June 7). New York managed care legislation: A model for other states. Washington, DC: Families USA. Available: http://epn.org/families/fastat.html
Families USA (1996, August). Kassebaum-Kennedy health insurance bill clears congress: Medicaid Saving Accounts cramped to demonstration program. Washington, DC: Families USA. Available: http://epn.org/families/fakeka.html
Fein, E. B. (1996, July 5). For-profit hospitals: Once unthinkable, now probably inevitable. The Current York Times, [On-line]. Available: http://www.nytimes.com
Freudenheim, M. (1996, July 16). Grading becomes stricter on health plans. The Novel York Times. [On-line]. Available: http://www.nytimes.com/sectionS/bUSiness
Health Care Portability and Accountability Act of 1996, Pub. L. No. 104-191 (1996).
Hoffman, C., Rice, D.R., & Sung, H.Y., (1996). Persons with chronic conditions: Their prevalence and costs. Journal of the American Medical Association,276,1473-1479.
Holusha, J. (1996, August18). For doctors togetherness is the original intention of life. The Novel York Times [On-line]. Available: http://www.nytimes.com/Cp960818.htfl1l
Levinson, M. (1996, June 26). As Blue Tainted and Blue Shield head into the for-profit sector, it is helping to initiate the biggest gold hasten since Sutter’s Mill. U.S.New [On-line]. Available: http:/ / www.usnews.com/
Levy, C. J. (1996, July 2). Unusual era in Recent York hospital-rate belief. The Modern York Times, pp. Al.
Malpractice law evolves under managed care. Paper presented at the conference, Emerging Liability Issues in Managed Care, sponsored by the Robert Wood Johnson Foundation’s Improving Malpractice Prevention and Compensation Systems (IMPACS) program, October, 1995.
Market competition and the health care safety rep. States of Health, (December, 1996) Washington, DC: Families USA. Available: http://epn.org/families/safeflet/html
Med-Access Search: Hospital Database. Available: http://medaccess.com/cgi/Hospital_basic.eXe
Metcalf, E. (1996, September 6). Columbia and Cornell opinion alliance—2,800 physicians strong.. Columbia University Spectator, p.1.
Metcalf, E. (1996, September 27). Columbia/Cornell MD’s Ally. Columbia University Describe, p. 1.
Nasr, H. (1996, July 31). Major university hospitals to merge. Columbia University Spectator, pp. 1,8.
Fresh York Health Reform Act of 1996, NY AB 11330.
Pear, R. (1996, May 26). Two trends collide: The rise in go and of local HMOs. The Recent York Times [On-line]. Available: http://www.nytimes.com
Perrin, E. C., Newacheck, P., Pless, B. I. Drotar, D., Gortmeaker, Steven, L., Leventhal, I., Perrin, J.M., Stein, R.E., Walker, D.E. Weitzman, M. (1993). Issues keen in the definition and classification of chronic health conditions. Pediatrics, 91(4), 787-793.
Robert Wood Johnson Foundation (December 1995). HealthTracking: HMOs and US health care. Available: http://rwjf.org
Robert Wood Johnson Foundation (February 1995). Market consolidation, antitrust, and public policy in the health care industry: Agenda for future research. Prepared for the council on the economic impact of health care reform (item: HTO1).
Robert Wood Johnson Foundation (December 1995). Health Tracking: HMOs and US health care. Available: http://rwjf.org
Robert Wood Johnson Foundation (February 1995). Market consolidation, antitrust, and public policy in the health care industry: Agenda for future research. Prepared for the council on the economic impact of health care reform (item: HTO1).Robinson, R. (1993). Economic evaluation in health care: Cost-effectiveness analysis. [Education & Debate]. The British Medical Journal,307(6907), 793-795.
Robinson, R. (1993). Economic evaluation in health care: Cost-effectiveness analysis. [Education & Debate]. The British Medical Journal,307(6909), 924-926.
Rosenthal, E. (1996, July 2). Two more hospitals bustle to join forces: Beth Israel-Long Island Jewish Merger to invent far-flung empire. The Original York Times, p. B3.
Rosenthal, E. (1996, July 15). Patients say NY 1-IMOs don’t deal well with complex illnesses. The Fresh York Times, p. Al.
Schiff, G. S. (1996, March 16). Managed care issues. Physicians for a National Health Belief. Available: pnhp@aol.com -
Selby, J. V., Fireman, B. H., & Swain, B.E. (1996). Accomplish of a copayment on employ of the emergency department in a health maintenance organization. New England Journal of Medicine, 334,635-641.
Shaw, T. (1996, March 25). Dole’s abominable medicine: health reform conception would raise costs, distress quality. USAToday, [On-line]. Distributed by the National Center for Policy Analysis.
Smolowe, J., Perman, S., & Van Tassel,J. (1996, April 15) A healthy merger? A grand deal makes Aetna the country’s largest health-care company. Time Magazine,14(16).
Spragins, E. (1996, September 24). Special Recount America’s best 1-IMOs: Rating the top managed care companies. Newsweek, pp.58-63.
Stone, D. A. (Monroe, J. A. & Beilcin, C. S. eds. 1994). The struggle for the soul of health insurance. The Politics of Health Care Reform,27-56.
Taylor, H. (1996, July 16). Health care capitalism remakes a city’s health system. The Albany Times [On-line]
Toim L (1996 July 31) Local 2110 loses its benefits Columbia University Spectator, pp 1-5
Van Duzer, K., & Nasr, H. (1996,July 31). Nurses reject final hospital’s offer, strike possible. Columbia University Spectator, pp. 1,8.
Ware, J.E., Bayliss, M.S., Rogers,W.H., Kosinski, M., Tarlov, A.R. (1996). Differences in 4-year health outcomes for elderly, awful, and chronically if patients treated in HMO and Fee-for-Service systems: Results construct a medical outcomes notice. Journal of the American Medical Association. L 1039-1047.
Williams, R. M. (1996). The cost of visits to emergency departments. New England Journal of Medicine, 334 642-646
Wines, M., & Pear, R. (1996, July 30). The President finds derive advantage from failure of health-care exertion. The Modern York Times [On-line]. Available: http://www.nytimes.cOm/web/dOcsroot/library/Politics/0730editon.html
