Underwriting the Social Contract: Distributive Justice & Health Care Reform
The Pickle Statement
As health care costs climbed exponentially in the 1980’s, so did the cost of health insurance plans. As a result, employers began to enroll their employees in managed care organizations, and many Americans were forced to leave their 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 nick 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 superb 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 definite 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 gather. 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 come by within the recent 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 reliable.
Health Insurance Portability Act of 1996
Two years after the Clinton Health Notion was defeated in Congress, Senator Ted Kennedy and Nancy Kassebaum introduced the Kennedy-Kassebaum Bill in response to growing concerns about selective enrollment procedures primitive 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 win 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 significant effort for those at risk for losing their health insurance. It does nothing to relieve the uninsured derive a decent health policy, and then provides no solution to the indispensable express 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 snarl of greatest pains to the citizens of this country: the cost of medical care. The Bill looks towards the states to invent 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 vital 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 assist 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 good mumble 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 eager in treatment studies. Each condition requires individualized treatment that cannot be based upon the simple economic/cost-benefit analysis aged in the utilization review process by mammoth insurance companies. Clearly, the most effective treatment for one patient may not be the best for another. The time required for utilization review may point to 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 back about 150,000 people.
Current 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 plot 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 detached subject to the utilization review process and access problems that mumble or delay medically valuable treatment (Donelan, et. al., Hoffman & Rice, 1996).
Underwriting the Solidarity Principle
Old-fashioned forms of insurance underwriting required that the contract explicitly location which illness or services are not covered by the policy, in arrive. If the underwriter did not specifically area 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 use more services. Insurers began to require health eye set questionnaires (refer to attachment A), and even began implementing AIDS and genetic testing to identify high-risk individuals (Brunetta, as cited in Gutmann & Thompson, 1996). In the 1980s, immense insurance companies began including sexual orientation as a high-risk category, by using actuarial sound criteria. Such criteria concluded that tickled 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 buy high-risk policies, the number of uninsured and underinsured Americans continues to grow exponentially (Durant, 1996).
More individuals are choosing not to capture insurance simply because they cannot afford it. Even among those with employer based health coverage, the policies frequently exclude coverage for long-term illness or care of chronic conditions (MSNBC News Forum, 1996). Without a standard definition of preexisting conditions, these clauses attend as “wildcards” since they allow insurers to squawk 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 narrate 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 expect medical histories of applicants and their families in order to identify high risk individuals (please refer to attachment A).
Legitimacy of Distributive Justice
While there is a legitimate role of government to distribute scarce resources among the nation’s neediest individuals, sadly this is not the cause for the mismanagement of medical dollars in the United States today. There is a great distinction between an individual being denied prescription medication at their local pharmacy due to a cost-effective formulary developed by their Managed Care Organizations (MCOs), than an individual being denied a liver transplant because healthy livers are a scarce resource. While both may have equally devastating consequences, it is more difficult to rationalize a lost life based upon rigid cost 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 scrape in distributive justice. Agreeable health is care is distinguished for pursuing most other things in life. Yet equal access to health care would require the government to not only redistribute resources from the rich, healthy to the terrible, and infirm, but also restrict the freedom of doctors and other health care providers. Such redistributions may be warranted, but to what level, and to what extent? ” Gutmann & Thompson (Page 178).
Blendon and his colleagues have reported similar findings in public thought polls from 1992 and 1994 (Blendon et. al., 1992; Blendon et. al., 1994). A unusual eye 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 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 plan polls reveal the legitimate role and public desire for government regulation of the health care industry. It has become definite 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. 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 anxiety about health care in this country, (1992, 1993, 1994, 1995, 1996).
Place 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. (Original York Times, 1996; The Recent York Daily News, 1996; Long Island Newsday, 1996; LA Times, 1996; Picayne Times, 1996; Columbia Spectator, 1996; Columbia University Narrate, 1996; US News & World Reports, 1996; Newsweek 1996; Healthline, 1996; The Tennessean, 1996; The Albany Times, 1996; The Nashville Scene, 1996). In their entirety, these case reports relate the human tragedy that lies beneath the web of the very worst of American capitalism: corporate greed.
Identifying Populations At-Risk
A seek 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 question their health care needs and expenditures to exceed that amount Regardless of health set, a young healthy 25 year broken-down who purchases an individual health insurance policy can question to pay well over $300.00 monthly for a health insurance policy with Empire Blue Shield Blue Depraved (based upon 1996 rates, original rates available from the Fresh York Situation Insurance Department).
Since individual policies are not addressed in the Health Insurance Portability and Accountability Act of 1996 (HIPA), an individual policy with Blue Unpleasant Blue Shield of Tennessee excludes preexisting conditions for 24 months (enrollment booklet available upon question). The significant markets in need of reform are the adversely selected individual insurance market, and the state’s most vulnerable populations: children; the elderly; the chronically ill; the uninsured; and the underinsured.
For the millions of individuals who have lost their employer based coverage, the cost of private health insurance is prohibitively expensive. Many individuals opt out of the individual market and apply for public assistance when the need arises. Those who have retained their health insurance coverage through their employers are being moved into managed care despite their efforts to hold their indemnity style plans (Davis & Shoen, 1996; The Lewison Group, 1996).
Access to Medical Care
As routine practice, HMOs sigh or delay care for all services that are not outright medically primary. Growing numbers of individuals have suffered irreparable wound, and many have died awaiting approval from their HMO’s (The Modern 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 expansive evidence that individuals with chronic conditions receive tainted care in HMOs.
A four-year longitudinal seek of medical outcomes found that the elderly, the awful, and persons with chronic conditions were in better health when covered by fee-for-service plans compared with a control group covered in HMOs (Ware et. al., 1996). Current statistics released in Washington, DC by the American Medical Association and the Robert Wood Johnson Foundation revealed the whisper costs of individuals with chronic conditions sage for 75% of reveal medical expenditures in the United States (Hoffman & Rice, 1996; based upon the National Medical Expenditures Survey; raw data available on CD from the Department of Health and Human Services Washington, DC). 45% of the American population suffers from at least one chronic illness.
If managed healthcare has been found to grunt inadequate care to this population, then we are looking at 100 million individuals who are potentially facing personal and financial crisis as they are moved into managed care. The public already accounts for the largest payment of divulge medical expenditures, which means the millions of dollars being made by for-profit insurance companies are not being circulated into the economy to help 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 conventional to fatten the pockets of CEO’s and majority stockholders (Healthline, 1996).
Based upon a current record from the Robert Wood Johnson Foundation, the scream costs for persons with chronic conditions narrate 69.4% of national expenditures in personal health care (Robert Wood Johnson Foundation, 1996). Their bid 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. Vast 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 graceful 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 scrape 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 dwelling 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 region courts for violations of the Medicaid Act (based upon a Lexis-Nexis search performed December 26, 1996). With the passing of H.R. 3507 into public law, (The Welfare Reform Bill) private citizens will gain shrimp reprieve in the federal courts, so any attempts to believe states accountable for violations of federal law will be extinct 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 mediate the public demands something more from physicians than to fair be a blob of bureaucrats, and I reflect we have to remove a stand now and then. Our role essentially as patient advocate, is to narrate 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 Assume Kessler eloquently stated as she handed down her decision in Salazar v. District of Columbia, No. 93-452, December 11, 1996, “tedious every fact found herein is a human face and the reality of being unpleasant in the richest nation on earth, (936 F. Supp. Bolt op. At 3).
Perhaps most distressing is the lack of accountability for mismanaged healthcare and ghastly denials of medically primary 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 station courts. The Supreme Court of the United States has agreed to hear Recent York’s ask for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the area of Recent 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 bewitch a serious notice at tort reform, and put a question to action by the Supreme Court as they advance the date of Unusual 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 dwelling courts. The court must uphold Daniels v. Wadley, and Salazar v. District of Columbia if further lives are to be saved in medicine rather than wasted away in the utilization review procedures. While we wait patiently for District of Columbia circuit court to order injunctive relief, the number of individuals suffering irreparable damage due to the systematic denial of medical care grows larger each day.
The history of Medicaid Managed Care does not provide a very optimistic survey 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 clear,” (Varley, as cited in Gutman & Thompson, I 996). This leaves me to wonder why the states continue to enroll their most vulnerable populations into a system of managed care that has proven to be a anguish.
Perhaps excellent of comment is that Arizona is the only location to have voted Republican in every election since 1948—certainly provides insight into the conservative morale of the area. Although Arizona was the last site to fetch the Medicaid cost sharing incentive proposed by the federal government in 1966, it was the first set to force its medically indigent population into managed care in 1981.
Violating Federal Law
Rigid pre-certification requirements and nonspecific utilization review procedures site strategic barriers to access medical treatment and services in Health Maintenance Organizations (HMOs). Pre-certification requirements are strategic barriers incorporated into the “murky box” of utilization review that institutionalizes exclusionary waiting periods and routine denials of medically distinguished treatment. According to federal law, “care and services are to be provided in a manner consistent with the simplicity of administration and the best interests of recipients,” (42 U.S.C. § I 396a (a) (19)). Clearly, such rigid pre-certification requirements that complicate administrative processing and paperwork on the section of the enrolled beneficiaries is a violation of United States Code.
Furthermore, using important care providers as a mechanism to limit access to specialists not only complicates administrative processing, but limits enrolled beneficiaries choice of health professionals beyond what is available to the general public in the geographic place (42 U.S.C. § 1 396a (a)(30)(A)). Certainly referral procedures do not “instruct 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 determine a indispensable care provider with more expertise than a nurse practitioner. I will argue that a neurologist is more familiar with the new needs of a patient with Multiple Sclerosis than a nurse practitioner is with slight 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 true to a elegant 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, terrible, and vulnerable—for whom life, in the memorable words of poet Langston Hughes, “ain’t been no crystal stair”. It is written in the dry and bloodless language of “the Iaw”—statistics, acronyms of agencies and bureaucratic entities, Supreme Court case names and quotes, official governmental reports, periodicity tables, etc. But let there be no forgetting the accurate people to whom this bloodless language gives voice: anxious working parents who are too abominable to accumulate medications or heart catheter procedures or lead poisoning screening for their children, AIDS patients unable to collect treatment, elderly persons suffering from chronic conditions like diabetes and heart disease who require constant monitoring arid medical attention. Late every fact found herein is a human face and the reality of being terrible in the richest nation on earth. (Hump 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 pleasurable 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 fraction of the general public is unable to secure health insurance coverage due to a preexisting condition, the more primary convey remains the cost of coverage. The cost of medical care will remain an mumble since fresh legislative efforts evade the protest. Unusual changes in the delivery of health services is of grave anxiety and different options must be considered in order to accept more effective ways to provide public and private assistance—MANAGED CARE IS NOT THE Retort!!! FOR-PROFIT HEALTH CARE IS NOT THE Acknowledge! PRIVATIZATION IS NOT THE Reply!
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Underwriting the Social Contract: Distributive Justice & Health Care Reform
The Plight Statement
As health care costs climbed exponentially in the 1980’s, so did the cost of health insurance plans. As a result, employers began to enroll their employees in managed care organizations, and many Americans were forced to leave their mature indemnity type plans. With the advent of the health maintenance organization, there is a financial incentive for the underutilization of care. (Blumstein, 1996; Davis & Shoen, 1996).
In order to slice financial risk, health insurance companies have restricted enrollment to individuals in bad 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 sure 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 procure. This is the least efficient manner to handle health care costs, and evades the premise that medical care is a natural legal in a civilized society. Few Americans feel acquire within the recent system. The rising costs of medical care contributed to the new market changes in both the administration and delivery of health services. The financial incentive to conceal only the healthiest individuals ignores the fact that medical care is a social great.
Health Insurance Portability Act of 1996
Two years after the Clinton Health Notion was defeated in Congress, Senator Ted Kennedy and Nancy Kassebaum introduced the Kennedy-Kassebaum Bill in response to growing concerns about selective enrollment procedures customary by health insurance companies in the private sector. In the final version of the Bill, insurance companies must limit preexisting condition clauses to twelve months. It has been estimated that this provision of the Bill will benefit an estimated 150,000 Americans procure 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 distinguished disaster for those at risk for losing their health insurance. It does nothing to aid the uninsured accept a decent health policy, and then provides no solution to the considerable assert 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 roar of greatest effort to the citizens of this country: the cost of medical care. The Bill looks towards the states to originate consumer protections and weakens the regulatory role of the federal government. The majority of the American public is unaware of the savor footwork fervent with this legislation, and the demographics of the population it is intended to protect. In order to assess the utility of this Bill, it is distinguished to identify the populations at risk for loosing health insurance coverage and the underinsured.
Kassebaum-Kennedy focuses on a slim 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 back 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 drawl at hand—the simple fact that the cost of quality health care in America is becoming a privilege that only the wealthy can afford.
The Cost of Care for Pre-existing Conditions
An individual with high blood pressure may impartial require prescription medication. Cancer patients in remission may require chemotherapy, and a person suffering with a degenerative disease may be enthusiastic in treatment studies. Each condition requires individualized treatment that cannot be based upon the simple economic/cost-benefit analysis aged in the utilization review process by ample insurance companies. Clearly, the most effective treatment for one patient may not be the best for another. The time required for utilization review may expose 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 ruin all in progressive legislation, however, in actuality it will only back about 150,000 people.
New studies have found that the majority of the uninsured population simply cannot afford to pay the premiums (Donelan et. al., 1996; Hoffman & Rice, 1996). According to their data, only 1% of the Uninsured population is due to original health residence 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 unruffled subject to the utilization review process and access problems that remark or delay medically critical treatment (Donelan, et. al., Hoffman & Rice, 1996).
Underwriting the Solidarity Principle
Mature forms of insurance underwriting required that the contract explicitly place which illness or services are not covered by the policy, in near. If the underwriter did not specifically location a positive 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 contemplate 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, mammoth insurance companies began including sexual orientation as a high-risk category, by using actuarial sound criteria. Such criteria concluded that pleased 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 exercise, insurance companies are able to offer rock bottom prices for young, healthy individuals. By excluding preexisting conditions and requiring obvious 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 steal 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 back as “wildcards” since they allow insurers to assert 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 declare 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 quiz 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 large 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 abet 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. Honorable health is care is notable for pursuing most other things in life. Yet equal access to health care would require the government to not only redistribute resources from the rich, healthy to the 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 notion polls from 1992 and 1994 (Blendon et. al., 1992; Blendon et. al., 1994). A unique inspect by the American Medical Association found cost to be of paramount exertion to an overwhelming number of Americans (Donelan et. aI., 1996). Of the 40 million uninsured Americans, only 1% attributes their failure to catch 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 understanding polls present the legitimate role and public desire for government regulation of the health care industry. It has become clear that the federal government must intervene in order to protect natural law rights, the social contract, and the Constitution of the United States. Regulation is needed to protect the individual freedoms, liberty, and the pursuit of “health, happiness, and the American Dream.”
If America is to be the “Land of Opportunity,” then clearly individual health and wellness should be an ideal to near for. Recent 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 difficulty about health care in this country, (1992, 1993, 1994, 1995, 1996).
Place 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. (Novel York Times, 1996; The Modern York Daily News, 1996; Long Island Newsday, 1996; LA Times, 1996; Picayne Times, 1996; Columbia Spectator, 1996; Columbia University Narrate, 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 leer by The Lewison Group in 1996 reveals insight into the private individual health insurance market. Clearly, individuals choosing to grasp health insurance policies for several hundred dollars each month request their health care needs and expenditures to exceed that amount Regardless of health place, a young healthy 25 year primitive 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 Inappropriate (based upon 1996 rates, new rates available from the Novel York Location Insurance Department).
Since individual policies are not addressed in the Health Insurance Portability and Accountability Act of 1996 (HIPA), an individual policy with Blue Putrid Blue Shield of Tennessee excludes preexisting conditions for 24 months (enrollment booklet available upon ask). The principal 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 mutter or delay care for all services that are not outright medically vital. Growing numbers of individuals have suffered irreparable distress, and many have died awaiting approval from their HMO’s (The Original York Times, 1996; Long Island Newsday, 1996; The Tennessean, 1996; Healthline, 1996). It is hardly a secret that HMOs have fallen short of their promise to provide comprehensive health care for the “whole” individual by emphasizing preventative medicine, using medical management to coordinate care. There is enormous evidence that individuals with chronic conditions receive ghastly care in HMOs.
A four-year longitudinal look of medical outcomes found that the elderly, the abominable, and persons with chronic conditions were in better health when covered by fee-for-service plans compared with a control group covered in HMOs (Ware et. al., 1996). Original statistics released in Washington, DC by the American Medical Association and the Robert Wood Johnson Foundation revealed the express costs of individuals with chronic conditions narrative for 75% of divulge medical expenditures in the United States (Hoffman & Rice, 1996; based upon the National Medical Expenditures Survey; raw data available on CD from the Department of Health and Human Services Washington, DC). 45% of the American population suffers from at least one chronic illness.
If managed healthcare has been found to stutter inadequate care to this population, then we are looking at 100 million individuals who are potentially facing personal and financial crisis as they are moved into managed care. The public already accounts for the largest payment of sing medical expenditures, which means the millions of dollars being made by for-profit insurance companies are not being circulated into the economy to help 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 ragged to fatten the pockets of CEO’s and majority stockholders (Healthline, 1996).
Based upon a unusual describe from the Robert Wood Johnson Foundation, the bellow costs for persons with chronic conditions recount 69.4% of national expenditures in personal health care (Robert Wood Johnson Foundation, 1996). Their exclaim 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 Peek 1987, not adjusted for inflation). This population is the most vulnerable to complications in their health and with their source of payment. Mammoth 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 dilemma of institutionalized waiting periods for medical appeals pending independent review by the Medical Review Unit (MRU), (42 U.S.C. § 1396 (a)(8)).
Furthermore, the court ordered federal injunctive protection to participants and beneficiaries because no region 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 accumulate limited reprieve in the federal courts, so any attempts to bear states accountable for violations of federal law will be stale at best (Denkeret. al., 1996).
Managed care has shown itself to be a farce of “medical management” in light of all the condemning evidence to the contrary. Timothy Icenogle, a medical doctor in the space of Arizona commented in 1981, “We play sort of an advocacy role. I reflect the public demands something more from physicians than to unbiased be a blob of bureaucrats, and I reflect we have to hold a stand now and then. Our role essentially as patient advocate, is to reveal them, well, impartial 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 Consider 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. Accelerate op. At 3).
Perhaps most distressing is the lack of accountability for mismanaged healthcare and spoiled denials of medically well-known 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 situation courts. The Supreme Court of the United States has agreed to hear Original York’s examine for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the area of Modern York.
When HMOs divulge care from patients, it is ludicrous to absorb individual physicians liable for the utilization decisions made by decentralized corporate review boards. It is time to choose a serious study at tort reform, and interrogate action by the Supreme Court as they arrive the date of Modern York’s ERISA hearing. A blanket court ruling upholding Daniels v. Wadley, and Salazar v. District of Columbia is desperately needed to avoid an avalanche of liability suits filed in site 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 injure due to the systematic denial of medical care grows larger each day.
The history of Medicaid Managed Care does not provide a very optimistic discover 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 wretchedness.
Perhaps good 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 status. Although Arizona was the last position to rep the Medicaid cost sharing incentive proposed by the federal government in 1966, it was the first spot to force its medically indigent population into managed care in 1981.
Violating Federal Law
Rigid pre-certification requirements and nonspecific utilization review procedures state strategic barriers to access medical treatment and services in Health Maintenance Organizations (HMOs). Pre-certification requirements are strategic barriers incorporated into the “shaded box” of utilization review that institutionalizes exclusionary waiting periods and routine denials of medically essential 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 essential 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 “express that recipients will have their choice of health professionals within the conception 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 considerable 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 limited 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 pleasing 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 proper people to whom this bloodless language gives voice: anxious working parents who are too dreadful to win medications or heart catheter procedures or lead poisoning screening for their children, AIDS patients unable to pick up 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. (Bolt 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 marvelous has removed millions of dollars from the healthcare marketplace with “medical loss ratios” of 57% compared to 85% in the conventional health insurance market
Although a slim share of the general public is unable to gain health insurance coverage due to a preexisting condition, the more important declare remains the cost of coverage. The cost of medical care will remain an order since current legislative efforts evade the divulge. Modern changes in the delivery of health services is of grave disaster and different options must be considered in order to derive more effective ways to provide public and private assistance—MANAGED CARE IS NOT THE Retort!!! FOR-PROFIT HEALTH CARE IS NOT THE Respond! PRIVATIZATION IS NOT THE Retort!
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