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 outmoded 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 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 helpful industry. The public sector absorbs the cost of unreimbursed care for chronic care in America (Robert Wood Johnson Foundation, 1996). Based upon these findings, it seems sure 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 accurate in a civilized society. Few Americans feel score within the novel system. The rising costs of medical care contributed to the novel market changes in both the administration and delivery of health services. The financial incentive to shroud only the healthiest individuals ignores the fact that medical care is a social trustworthy.
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 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 assist an estimated 150,000 Americans collect 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 important effort for those at risk for losing their health insurance. It does nothing to attend the uninsured fetch a decent health policy, and then provides no solution to the principal notify 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 screech of greatest grief 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 admire footwork interested with this legislation, and the demographics of the population it is intended to protect. In order to assess the utility of this Bill, it is vital to identify the populations at risk for loosing health insurance coverage and the underinsured.
Kassebaum-Kennedy focuses on a slim fragment of the uninsured population, and those who would be eligible for COBRA continuation (Consolidated Omnibus Reconciliation Act of 1974). Of the 41 million uninsured Americans, only about 150,000 are expected to 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 good relate at hand—the simple fact that the cost of quality health care in America is becoming a privilege that only the wealthy can afford.
The Cost of Care for Pre-existing Conditions
An individual with high blood pressure may fair require prescription medication. Cancer patients in remission may require chemotherapy, and a person suffering with a degenerative disease may be enthusiastic in treatment studies. Each condition requires individualized treatment that cannot be based upon the simple economic/cost-benefit analysis passe in the utilization review process by vast insurance companies. Clearly, the most effective treatment for one patient may not be the best for another. The time required for utilization review may demonstrate 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 fresh 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 unruffled subject to the utilization review process and access problems that command or delay medically significant treatment (Donelan, et. al., Hoffman & Rice, 1996).
Underwriting the Solidarity Principle
Ancient 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 region 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 spend more services. Insurers began to require health witness situation questionnaires (refer to attachment A), and even began implementing AIDS and genetic testing to identify high-risk individuals (Brunetta, as cited in Gutmann & Thompson, 1996). In the 1980s, tremendous 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 expend, 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 catch 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 wait on as “wildcards” since they allow insurers to recount 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 shriek 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 expansive distinction between an individual being denied prescription medication at their local pharmacy due to a cost-effective formulary developed by their Managed Care Organizations (MCOs), than an individual being denied a liver transplant because healthy livers are a scarce resource. While both may have equally devastating consequences, it is more difficult to rationalize a lost life based upon rigid cost aid analysis and utilization decisions made according to formulas and cost-benefit analysis of treatment protocols.
“The political controversy over the distribution of health care in the United States is an instructive quandary in distributive justice. Honorable health is care is famous 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 abominable, 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 idea polls from 1992 and 1994 (Blendon et. al., 1992; Blendon et. al., 1994). A unusual scrutinize by the American Medical Association found cost to be of paramount trouble to an overwhelming number of Americans (Donelan et. aI., 1996). Of the 40 million uninsured Americans, only 1% attributes their failure to accumulate health insurance coverage to their preexisting conditions. Among the uninsured, cost is cited as the notable obstacle in obtaining health insurance coverage. Only 1% of the uninsured attributes their lack of coverage to a preexisting condition.
Based upon these democratic principles of distributive justice, consistent conception polls reveal the legitimate role and public desire for government regulation of the health care industry. It has become positive that the federal government must intervene in order to protect natural law rights, the social contract, and the Constitution of the United States. Regulation is needed to protect the individual freedoms, liberty, and the pursuit of “health, happiness, and the American Dream.”
If America is to be the “Land of Opportunity,” then clearly individual health and wellness should be an ideal to arrive for. New 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 distress about health care in this country, (1992, 1993, 1994, 1995, 1996).
Dwelling 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 Recount, 1996; US News & World Reports, 1996; Newsweek 1996; Healthline, 1996; The Tennessean, 1996; The Albany Times, 1996; The Nashville Scene, 1996). In their entirety, these case reports picture the human tragedy that lies beneath the web of the very worst of American capitalism: corporate greed.
Identifying Populations At-Risk
A view by The Lewison Group in 1996 reveals insight into the private individual health insurance market. Clearly, individuals choosing to rob health insurance policies for several hundred dollars each month quiz their health care needs and expenditures to exceed that amount Regardless of health situation, a young healthy 25 year faded who purchases an individual health insurance policy can query to pay well over $300.00 monthly for a health insurance policy with Empire Blue Shield Blue Tainted (based upon 1996 rates, fresh rates available from the Unique York Region Insurance Department).
Since individual policies are not addressed in the Health Insurance Portability and Accountability Act of 1996 (HIPA), an individual policy with Blue Despicable Blue Shield of Tennessee excludes preexisting conditions for 24 months (enrollment booklet available upon seek information from). The vital markets in need of reform are the adversely selected individual insurance market, and the state’s most vulnerable populations: children; the elderly; the chronically ill; the uninsured; and the underinsured.
For the millions of individuals who have lost their employer based coverage, the cost of private health insurance is prohibitively expensive. Many individuals opt out of the individual market and apply for public assistance when the need arises. Those who have retained their health insurance coverage through their employers are being moved into managed care despite their efforts to keep their indemnity style plans (Davis & Shoen, 1996; The Lewison Group, 1996).
Access to Medical Care
As routine practice, HMOs allege or delay care for all services that are not outright medically important. Growing numbers of individuals have suffered irreparable pain, 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 mammoth evidence that individuals with chronic conditions receive defective care in HMOs.
A four-year longitudinal gaze of medical outcomes found that the elderly, the awful, and persons with chronic conditions were in better health when covered by fee-for-service plans compared with a control group covered in HMOs (Ware et. al., 1996). Unusual statistics released in Washington, DC by the American Medical Association and the Robert Wood Johnson Foundation revealed the insist costs of individuals with chronic conditions record for 75% of teach 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 insist 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 narrate 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 extinct to fatten the pockets of CEO’s and majority stockholders (Healthline, 1996).
Based upon a fresh record from the Robert Wood Johnson Foundation, the explain costs for persons with chronic conditions narrate 69.4% of national expenditures in personal health care (Robert Wood Johnson Foundation, 1996). Their divulge 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 Gape 1987, not adjusted for inflation). This population is the most vulnerable to complications in their health and with their source of payment. Great insurance companies only provide adequate coverage for acute illness (Donelan et al., 1996; Hoffman et. al, 1996).
Medicaid Managed Care
Following Tennessee’s lead, many states have enrolled their medically indigent populations in Medicaid Managed Care Organizations (MCOs). In Daniels v. Wadley, (926 F. Supp. 1305), the court held that TennCare violated the Due Process Clause of the Fourteenth Amendment since such procedures eliminate gorgeous hearings and independent medical review of disputes. The court found the pattern of routine denials of care by MCOs participating in the states TennCare program to violate the Medicaid Act since it compounded the predicament of institutionalized waiting periods for medical appeals pending independent review by the Medical Review Unit (MRU), (42 U.S.C. § 1396 (a)(8)).
Furthermore, the court ordered federal injunctive protection to participants and beneficiaries because no position 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 earn miniature reprieve in the federal courts, so any attempts to believe 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 spot of Arizona commented in 1981, “We play sort of an advocacy role. I judge the public demands something more from physicians than to unbiased be a blob of bureaucrats, and I reflect we have to prefer a stand now and then. Our role essentially as patient advocate, is to philosophize them, well, honest because the insurance company is not going to pay, that is not the waste 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, “slack every fact found herein is a human face and the reality of being bad in the richest nation on earth, (936 F. Supp. Hotfoot op. At 3).
Perhaps most distressing is the lack of accountability for mismanaged healthcare and corrupt 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 principal human resources as we await decisions to be handed down from place courts. The Supreme Court of the United States has agreed to hear Modern York’s examine for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the site of Novel York.
When HMOs affirm care from patients, it is ludicrous to bear individual physicians liable for the utilization decisions made by decentralized corporate review boards. It is time to retract a serious peer at tort reform, and question action by the Supreme Court as they come the date of Recent York’s ERISA hearing. A blanket court ruling upholding Daniels v. Wadley, and Salazar v. District of Columbia is desperately needed to avoid an avalanche of liability suits filed in plot 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 wound due to the systematic denial of medical care grows larger each day.
The history of Medicaid Managed Care does not provide a very optimistic glimpse 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 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 trouble.
Perhaps suitable of comment is that Arizona is the only dwelling to have voted Republican in every election since 1948—certainly provides insight into the conservative morale of the plot. Although Arizona was the last location to catch the Medicaid cost sharing incentive proposed by the federal government in 1966, it was the first site to force its medically indigent population into managed care in 1981.
Violating Federal Law
Rigid pre-certification requirements and nonspecific utilization review procedures space strategic barriers to access medical treatment and services in Health Maintenance Organizations (HMOs). Pre-certification requirements are strategic barriers incorporated into the “dim box” of utilization review that institutionalizes exclusionary waiting periods and routine denials of medically indispensable 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 allotment of the enrolled beneficiaries is a violation of United States Code.
Furthermore, using distinguished 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 plot (42 U.S.C. § 1 396a (a)(30)(A)). Certainly referral procedures do not “suppose that recipients will have their choice of health professionals within the concept 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 principal care provider with more expertise than a nurse practitioner. I will argue that a neurologist is more familiar with the fresh needs of a patient with Multiple Sclerosis than a nurse practitioner is with miniature 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 correct to a heavenly hearing in front of an unbiased independent Medical Review Unit (MRU). Furthermore, the Medicaid Act clearly states that medical services for a Medicaid beneficiary may not be terminated until the said beneficiary receives such a hearing
Conclusion
The country as a whole must realize what Assume 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 accurate 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 bag 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. (Stride op. At 3). -Judge Gladys Kessler, December 11, 1996.
Patients are routinely being denied medical care– and being forced into a system that incorporates long waiting periods into their physician contracts and handbooks (Green, 1996). The private for-profit insurance industry has single-handedly undermined the solidarity principle of health insurance by using strict underwriting techniques, ridiculous treatment protocols; inconsistent definitions of chronic illness and rigid utilization review procedures unavailable to the consumer; and inconsistent definitions of “chronic illness” and “emergency” (Dallek, 1996). It is an industry which justified using sexual orientation to avoid covering AIDS patients, calling such methods “actuarially sound.” The privatization of a public expedient has removed millions of dollars from the healthcare marketplace with “medical loss ratios” of 57% compared to 85% in the venerable health insurance market
Although a slim fraction of the general public is unable to earn health insurance coverage due to a preexisting condition, the more considerable tell remains the cost of coverage. The cost of medical care will remain an impart since novel legislative efforts evade the declare. Fresh changes in the delivery of health services is of grave trouble and different options must be considered in order to come by more effective ways to provide public and private assistance—MANAGED CARE IS NOT THE Reply!!! FOR-PROFIT HEALTH CARE IS NOT THE Respond! PRIVATIZATION IS NOT THE Respond!
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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 feeble indemnity type plans. With the advent of the health maintenance organization, there is a financial incentive for the underutilization of care. (Blumstein, 1996; Davis & Shoen, 1996).
In order to chop 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 pleasant industry. The public sector absorbs the cost of unreimbursed care for chronic care in America (Robert Wood Johnson Foundation, 1996). Based upon these findings, it seems distinct that the money being removed from the health care marketplace is fattening the pockets of CEOs and majority stockholders.
Novel trend towards localized government leaves individuals without a financial safety salvage. This is the least efficient manner to handle health care costs, and evades the premise that medical care is a natural correct in a civilized society. Few Americans feel procure within the recent system. The rising costs of medical care contributed to the original market changes in both the administration and delivery of health services. The financial incentive to conceal only the healthiest individuals ignores the fact that medical care is a social capable.
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 faded by health insurance companies in the private sector. In the final version of the Bill, insurance companies must limit preexisting condition clauses to twelve months. It has been estimated that this provision of the Bill will relieve an estimated 150,000 Americans 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 notable misfortune for those at risk for losing their health insurance. It does nothing to benefit the uninsured win a decent health policy, and then provides no solution to the principal announce 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 articulate of greatest effort to the citizens of this country: the cost of medical care. The Bill looks towards the states to build consumer protections and weakens the regulatory role of the federal government. The majority of the American public is unaware of the esteem footwork interested with this legislation, and the demographics of the population it is intended to protect. In order to assess the utility of this Bill, it is vital to identify the populations at risk for loosing health insurance coverage and the underinsured.
Kassebaum-Kennedy focuses on a slim share 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 apt content 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 unbiased require prescription medication. Cancer patients in remission may require chemotherapy, and a person suffering with a degenerative disease may be keen in treatment studies. Each condition requires individualized treatment that cannot be based upon the simple economic/cost-benefit analysis worn in the utilization review process by titanic 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 slay all in progressive legislation, however, in actuality it will only abet 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 novel 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 quiet subject to the utilization review process and access problems that inform or delay medically significant treatment (Donelan, et. al., Hoffman & Rice, 1996).
Underwriting the Solidarity Principle
Feeble forms of insurance underwriting required that the contract explicitly dwelling which illness or services are not covered by the policy, in arrive. If the underwriter did not specifically site 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 use more services. Insurers began to require health gaze site 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, grand insurance companies began including sexual orientation as a high-risk category, by using actuarial sound criteria. Such criteria concluded that blissful men were a higher risk for contracting AIDS virus and refused to write policies for anyone believed to be homosexual, (Stone, 1994 as cited in Durant, 1996).
By limiting enrollment to the healthiest members of society, selective enrollment undermines the solidarity principle of health insurance (Davis & Shoen, 1996; Snow, 1996; Stone, 1994). By eliminating those who were suspect of using more services than their healthier counterparts exercise, insurance companies are able to offer rock bottom prices for young, healthy individuals. By excluding preexisting conditions and requiring sure individuals to occupy high-risk policies, the number of uninsured and underinsured Americans continues to grow exponentially (Durant, 1996).
More individuals are choosing not to acquire 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 issue coverage for any illness that “manifested itself before the issuing date of the policy (Stone, 1994 as cited in Durant, 1996).
This statement allows insurers to snarl treatment for benefits and services for the policyholder for undiagnosed illnesses or conditions of which they were unaware. As a result, the insurers began to seek information from 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 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 pickle in distributive justice. Great health is care is well-known for pursuing most other things in life. Yet equal access to health care would require the government to not only redistribute resources from the rich, healthy to the awful, and infirm, but also restrict the freedom of doctors and other health care providers. Such redistributions may be warranted, but to what level, and to what extent? ” Gutmann & Thompson (Page 178).
Blendon and his colleagues have reported similar findings in public conception polls from 1992 and 1994 (Blendon et. al., 1992; Blendon et. al., 1994). A fresh contemplate 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 score 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 view polls point to the legitimate role and public desire for government regulation of the health care industry. It has become determined that the federal government must intervene in order to protect natural law rights, the social contract, and the Constitution of the United States. Regulation is needed to protect the individual freedoms, liberty, and the pursuit of “health, happiness, and the American Dream.”
If America is to be the “Land of Opportunity,” then clearly individual health and wellness should be an ideal to come for. 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 distress about health care in this country, (1992, 1993, 1994, 1995, 1996).
Dwelling civil courts are backed up with cases where HMOs have violated the First Amendment (gag orders), the Fourteenth Amendment (due process), and the rights of protected classes under the Americans with Disabilities Act. Countless examples of “anecdotal” evidence appear as headlines everyday across the country. (Recent York Times, 1996; The Original 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 relate the human tragedy that lies beneath the web of the very worst of American capitalism: corporate greed.
Identifying Populations At-Risk
A explore by The Lewison Group in 1996 reveals insight into the private individual health insurance market. Clearly, individuals choosing to seize health insurance policies for several hundred dollars each month request their health care needs and expenditures to exceed that amount Regardless of health space, a young healthy 25 year ancient 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 Evil (based upon 1996 rates, fresh rates available from the Unusual York Space Insurance Department).
Since individual policies are not addressed in the Health Insurance Portability and Accountability Act of 1996 (HIPA), an individual policy with Blue Contaminated Blue Shield of Tennessee excludes preexisting conditions for 24 months (enrollment booklet available upon question). The important markets in need of reform are the adversely selected individual insurance market, and the state’s most vulnerable populations: children; the elderly; the chronically ill; the uninsured; and the underinsured.
For the millions of individuals who have lost their employer based coverage, the cost of private health insurance is prohibitively expensive. Many individuals opt out of the individual market and apply for public assistance when the need arises. Those who have retained their health insurance coverage through their employers are being moved into managed care despite their efforts to preserve their indemnity style plans (Davis & Shoen, 1996; The Lewison Group, 1996).
Access to Medical Care
As routine practice, HMOs dispute or delay care for all services that are not outright medically well-known. Growing numbers of individuals have suffered irreparable wound, and many have died awaiting approval from their HMO’s (The Fresh York Times, 1996; Long Island Newsday, 1996; The Tennessean, 1996; Healthline, 1996). It is hardly a secret that HMOs have fallen short of their promise to provide comprehensive health care for the “whole” individual by emphasizing preventative medicine, using medical management to coordinate care. There is colossal evidence that individuals with chronic conditions receive nefarious 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). Recent statistics released in Washington, DC by the American Medical Association and the Robert Wood Johnson Foundation revealed the explain costs of individuals with chronic conditions epic for 75% of protest 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 roar 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 protest medical expenditures, which means the millions of dollars being made by for-profit insurance companies are not being circulated into the economy to abet in public health costs care. The industry made a 14.8% profit in the 3rd quarter of 1996, however these medical dollars were removed from health care and stale to fatten the pockets of CEO’s and majority stockholders (Healthline, 1996).
Based upon a recent recount from the Robert Wood Johnson Foundation, the sigh costs for persons with chronic conditions characterize 69.4% of national expenditures in personal health care (Robert Wood Johnson Foundation, 1996). Their say medical costs are estimated at $4672.00 annually compared with $817.00 annually for individuals with acute illness (Hoffman & Rice, 1996; based upon National Medical Expenditures See 1987, not adjusted for inflation). This population is the most vulnerable to complications in their health and with their source of payment. Tall 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 jam 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 residence 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 space 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 secure small reprieve in the federal courts, so any attempts to have states accountable for violations of federal law will be aged at best (Denkeret. al., 1996).
Managed care has shown itself to be a farce of “medical management” in light of all the condemning evidence to the contrary. Timothy Icenogle, a medical doctor in the site of Arizona commented in 1981, “We play sort of an advocacy role. I contemplate the public demands something more from physicians than to fair be a blob of bureaucrats, and I contemplate we have to steal a stand now and then. Our role essentially as patient advocate, is to sigh them, well, unprejudiced because the insurance company is not going to pay, that is not the ruin of all the resources,” (Icenogle, as cited in Gutmann & Thompson, 1996). Never has this statement been needed more than it is today. Unfortunately, as more insurance companies refuse to pay for medical treatment, fewer resources become available for patients in desperate need of financial assistance. As Assume Kessler eloquently stated as she handed down her decision in Salazar v. District of Columbia, No. 93-452, December 11, 1996, “slack every fact found herein is a human face and the reality of being abominable in the richest nation on earth, (936 F. Supp. Trip op. At 3).
Perhaps most distressing is the lack of accountability for mismanaged healthcare and depraved denials of medically considerable 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 famous human resources as we await decisions to be handed down from place courts. The Supreme Court of the United States has agreed to hear Recent York’s expect for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the dwelling of Unique York.
When HMOs allege care from patients, it is ludicrous to contain individual physicians liable for the utilization decisions made by decentralized corporate review boards. It is time to buy a serious explore at tort reform, and examine action by the Supreme Court as they come 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 pain due to the systematic denial of medical care grows larger each day.
The history of Medicaid Managed Care does not provide a very optimistic discover 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 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 peril.
Perhaps obliging of comment is that Arizona is the only area to have voted Republican in every election since 1948—certainly provides insight into the conservative morale of the region. Although Arizona was the last region to come by the Medicaid cost sharing incentive proposed by the federal government in 1966, it was the first position to force its medically indigent population into managed care in 1981.
Violating Federal Law
Rigid pre-certification requirements and nonspecific utilization review procedures position 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 principal treatment. According to federal law, “care and services are to be provided in a manner consistent with the simplicity of administration and the best interests of recipients,” (42 U.S.C. § I 396a (a) (19)). Clearly, such rigid pre-certification requirements that complicate administrative processing and paperwork on the allotment of the enrolled beneficiaries is a violation of United States Code.
Furthermore, using well-known 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 “explain that recipients will have their choice of health professionals within the notion 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 principal 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 minute 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 honest to a blooming hearing in front of an just independent Medical Review Unit (MRU). Furthermore, the Medicaid Act clearly states that medical services for a Medicaid beneficiary may not be terminated until the said beneficiary receives such a hearing
Conclusion
The country as a whole must realize what Reflect 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 right people to whom this bloodless language gives voice: anxious working parents who are too abominable to collect medications or heart catheter procedures or lead poisoning screening for their children, AIDS patients unable to score 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 terrible in the richest nation on earth. (Scuttle op. At 3). -Judge Gladys Kessler, December 11, 1996.
Patients are routinely being denied medical care– and being forced into a system that incorporates long waiting periods into their physician contracts and handbooks (Green, 1996). The private for-profit insurance industry has single-handedly undermined the solidarity principle of health insurance by using strict underwriting techniques, ridiculous treatment protocols; inconsistent definitions of chronic illness and rigid utilization review procedures unavailable to the consumer; and inconsistent definitions of “chronic illness” and “emergency” (Dallek, 1996). It is an industry which justified using sexual orientation to avoid covering AIDS patients, calling such methods “actuarially sound.” The privatization of a public honorable has removed millions of dollars from the healthcare marketplace with “medical loss ratios” of 57% compared to 85% in the primitive health insurance market
Although a slim piece of the general public is unable to salvage health insurance coverage due to a preexisting condition, the more significant recount remains the cost of coverage. The cost of medical care will remain an philosophize since novel legislative efforts evade the thunder. Fresh changes in the delivery of health services is of grave disaster and different options must be considered in order to gain 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 Acknowledge!
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