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 ragged 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 carve financial risk, health insurance companies have restricted enrollment to individuals in terrible health. By covering the minimal standards of treatment and excluding high risk groups altogether, major US insurance companies have realized that the health insurance market can a be an extremely generous 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 certain 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 bag. This is the least efficient manner to handle health care costs, and evades the premise that medical care is a natural moral in a civilized society. Few Americans feel procure within the original system. The rising costs of medical care contributed to the novel market changes in both the administration and delivery of health services. The financial incentive to hide only the healthiest individuals ignores the fact that medical care is a social qualified.
Health Insurance Portability Act of 1996
Two years after the Clinton Health Concept was defeated in Congress, Senator Ted Kennedy and Nancy Kassebaum introduced the Kennedy-Kassebaum Bill in response to growing concerns about selective enrollment procedures feeble by health insurance companies in the private sector. In the final version of the Bill, insurance companies must limit preexisting condition clauses to twelve months. It has been estimated that this provision of the Bill will serve an estimated 150,000 Americans bag 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 indispensable inconvenience for those at risk for losing their health insurance. It does nothing to befriend the uninsured salvage a decent health policy, and then provides no solution to the famous grunt at hand— cost
Since Kennedy-Kassebaum does nothing to control the cost of health insurance and medical care in America, the Bill fails to retort to the snort of greatest trouble to the citizens of this country: the cost of medical care. The Bill looks towards the states to manufacture consumer protections and weakens the regulatory role of the federal government. The majority of the American public is unaware of the care for footwork enthusiastic with this legislation, and the demographics of the population it is intended to protect. In order to assess the utility of this Bill, it is famous to identify the populations at risk for loosing health insurance coverage and the underinsured.
Kassebaum-Kennedy focuses on a slim fraction of the uninsured population, and those who would be eligible for COBRA continuation (Consolidated Omnibus Reconciliation Act of 1974). Of the 41 million uninsured Americans, only about 150,000 are expected to abet 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 enlighten 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 traditional 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 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 extinguish all in progressive legislation, however, in actuality it will only relieve 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 fresh health region 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 serene subject to the utilization review process and access problems that disclose or delay medically distinguished treatment (Donelan, et. al., Hoffman & Rice, 1996).
Underwriting the Solidarity Principle
Weak forms of insurance underwriting required that the contract explicitly space which illness or services are not covered by the policy, in arrive. If the underwriter did not specifically spot 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 witness space questionnaires (refer to attachment A), and even began implementing AIDS and genetic testing to identify high-risk individuals (Brunetta, as cited in Gutmann & Thompson, 1996). In the 1980s, mammoth insurance companies began including sexual orientation as a high-risk category, by using actuarial sound criteria. Such criteria concluded that elated men were a higher risk for contracting AIDS virus and refused to write policies for anyone believed to be homosexual, (Stone, 1994 as cited in Durant, 1996).
By limiting enrollment to the healthiest members of society, selective enrollment undermines the solidarity principle of health insurance (Davis & Shoen, 1996; Snow, 1996; Stone, 1994). By eliminating those who were suspect of using more services than their healthier counterparts exhaust, insurance companies are able to offer rock bottom prices for young, healthy individuals. By excluding preexisting conditions and requiring obvious individuals to lift high-risk policies, the number of uninsured and underinsured Americans continues to grow exponentially (Durant, 1996).
More individuals are choosing not to hold 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 benefit as “wildcards” since they allow insurers to snort 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 pronounce treatment for benefits and services for the policyholder for undiagnosed illnesses or conditions of which they were unaware. As a result, the insurers began to question medical histories of applicants and their families in order to identify high risk individuals (please refer to attachment A).
Legitimacy of Distributive Justice
While there is a legitimate role of government to distribute scarce resources among the nation’s neediest individuals, sadly this is not the cause for the mismanagement of medical dollars in the United States today. There is a mountainous distinction between an individual being denied prescription medication at their local pharmacy due to a cost-effective formulary developed by their Managed Care Organizations (MCOs), than an individual being denied a liver transplant because healthy livers are a scarce resource. While both may have equally devastating consequences, it is more difficult to rationalize a lost life based upon rigid cost befriend analysis and utilization decisions made according to formulas and cost-benefit analysis of treatment protocols.
“The political controversy over the distribution of health care in the United States is an instructive spot in distributive justice. Grand health is care is important for pursuing most other things in life. Yet equal access to health care would require the government to not only redistribute resources from the rich, healthy to the dreadful, and infirm, but also restrict the freedom of doctors and other health care providers. Such redistributions may be warranted, but to what level, and to what extent? ” Gutmann & Thompson (Page 178).
Blendon and his colleagues have reported similar findings in public belief polls from 1992 and 1994 (Blendon et. al., 1992; Blendon et. al., 1994). A modern eye by the American Medical Association found cost to be of paramount anguish to an overwhelming number of Americans (Donelan et. aI., 1996). Of the 40 million uninsured Americans, only 1% attributes their failure to find health insurance coverage to their preexisting conditions. Among the uninsured, cost is cited as the considerable 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 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 come for. Fresh 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 peril about health care in this country, (1992, 1993, 1994, 1995, 1996).
Position civil courts are backed up with cases where HMOs have violated the First Amendment (gag orders), the Fourteenth Amendment (due process), and the rights of protected classes under the Americans with Disabilities Act. Countless examples of “anecdotal” evidence appear as headlines everyday across the country. (Fresh York Times, 1996; The Unique York Daily News, 1996; Long Island Newsday, 1996; LA Times, 1996; Picayne Times, 1996; Columbia Spectator, 1996; Columbia University Characterize, 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 record the human tragedy that lies beneath the web of the very worst of American capitalism: corporate greed.
Identifying Populations At-Risk
A gawk by The Lewison Group in 1996 reveals insight into the private individual health insurance market. Clearly, individuals choosing to lift health insurance policies for several hundred dollars each month ask their health care needs and expenditures to exceed that amount Regardless of health area, a young healthy 25 year frail who purchases an individual health insurance policy can ask to pay well over $300.00 monthly for a health insurance policy with Empire Blue Shield Blue Substandard (based upon 1996 rates, original rates available from the Original York Site Insurance Department).
Since individual policies are not addressed in the Health Insurance Portability and Accountability Act of 1996 (HIPA), an individual policy with Blue Wrong Blue Shield of Tennessee excludes preexisting conditions for 24 months (enrollment booklet available upon demand). The considerable 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 maintain their indemnity style plans (Davis & Shoen, 1996; The Lewison Group, 1996).
Access to Medical Care
As routine practice, HMOs express or delay care for all services that are not outright medically indispensable. Growing numbers of individuals have suffered irreparable hurt, 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 immense evidence that individuals with chronic conditions receive evil care in HMOs.
A four-year longitudinal search for 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). Current statistics released in Washington, DC by the American Medical Association and the Robert Wood Johnson Foundation revealed the relate costs of individuals with chronic conditions memoir for 75% of train 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 announce 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 content medical expenditures, which means the millions of dollars being made by for-profit insurance companies are not being circulated into the economy to relieve in public health costs care. The industry made a 14.8% profit in the 3rd quarter of 1996, however these medical dollars were removed from health care and old-fashioned to fatten the pockets of CEO’s and majority stockholders (Healthline, 1996).
Based upon a unique characterize from the Robert Wood Johnson Foundation, the say costs for persons with chronic conditions recount 69.4% of national expenditures in personal health care (Robert Wood Johnson Foundation, 1996). Their converse 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 Gaze 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 sparkling 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 set law may preempt federal law by depriving individuals of their constitutional rights. The Department of Health and Human Services (HHS) was ordered to revise its utilization review procedures for TennCare recipients in keeping with the Medicaid Act (42 U.S.C. § 1396 (a) (8)) ensuring due process protections for all covered beneficiaries by requiring “services are provided with ‘reasonable promptness,’” (926 F. Supp. 1305).
This case is one of 543 civil suits pending in the position courts for violations of the Medicaid Act (based upon a Lexis-Nexis search performed December 26, 1996). With the passing of H.R. 3507 into public law, (The Welfare Reform Bill) private citizens will regain itsy-bitsy reprieve in the federal courts, so any attempts to have states accountable for violations of federal law will be old 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 dwelling of Arizona commented in 1981, “We play sort of an advocacy role. I judge the public demands something more from physicians than to objective be a blob of bureaucrats, and I assume we have to buy a stand now and then. Our role essentially as patient advocate, is to declare them, well, unbiased because the insurance company is not going to pay, that is not the slay of all the resources,” (Icenogle, as cited in Gutmann & Thompson, 1996). Never has this statement been needed more than it is today. Unfortunately, as more insurance companies refuse to pay for medical treatment, fewer resources become available for patients in desperate need of financial assistance. As Mediate Kessler eloquently stated as she handed down her decision in Salazar v. District of Columbia, No. 93-452, December 11, 1996, “slow every fact found herein is a human face and the reality of being dreadful in the richest nation on earth, (936 F. Supp. Mosey op. At 3).
Perhaps most distressing is the lack of accountability for mismanaged healthcare and nasty 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 notable human resources as we await decisions to be handed down from spot courts. The Supreme Court of the United States has agreed to hear Unique York’s question for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the spot of Original York.
When HMOs exclaim 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 choose a serious explore at tort reform, and ask action by the Supreme Court as they reach 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 situation 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 observe into the future of TennCare recipients and Medicaid beneficiaries in states around the country. Dating benefit to the implementation of the Arizona Health Care Cost Containment System (AHCCCS) in 1981, there are documented cases where “people reportedly died for lack of medical treatment before their eligibility was 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 danger.
Perhaps proper 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 area. Although Arizona was the last region to bag the Medicaid cost sharing incentive proposed by the federal government in 1966, it was the first plot 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 “sad box” of utilization review that institutionalizes exclusionary waiting periods and routine denials of medically famous treatment. According to federal law, “care and services are to be provided in a manner consistent with the simplicity of administration and the best interests of recipients,” (42 U.S.C. § I 396a (a) (19)). Clearly, such rigid pre-certification requirements that complicate administrative processing and paperwork on the fragment of the enrolled beneficiaries is a violation of United States Code.
Furthermore, using famous 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 residence (42 U.S.C. § 1 396a (a)(30)(A)). Certainly referral procedures do not “exclaim 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 valuable 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 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 upright to a splendid hearing in front of an honest independent Medical Review Unit (MRU). Furthermore, the Medicaid Act clearly states that medical services for a Medicaid beneficiary may not be terminated until the said beneficiary receives such a hearing
Conclusion
The country as a whole must realize what 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, bad, and vulnerable—for whom life, in the memorable words of poet Langston Hughes, “ain’t been no crystal stair”. It is written in the dry and bloodless language of “the Iaw”—statistics, acronyms of agencies and bureaucratic entities, Supreme Court case names and quotes, official governmental reports, periodicity tables, etc. But let there be no forgetting the steady people to whom this bloodless language gives voice: anxious working parents who are too terrible to secure medications or heart catheter procedures or lead poisoning screening for their children, AIDS patients unable to salvage treatment, elderly persons suffering from chronic conditions like diabetes and heart disease who require constant monitoring arid medical attention. Late every fact found herein is a human face and the reality of being unpleasant in the richest nation on earth. (Gallop 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 estimable has removed millions of dollars from the healthcare marketplace with “medical loss ratios” of 57% compared to 85% in the former health insurance market
Although a slim fraction of the general public is unable to come by health insurance coverage due to a preexisting condition, the more distinguished grunt remains the cost of coverage. The cost of medical care will remain an negate since original legislative efforts evade the screech. New changes in the delivery of health services is of grave grief and different options must be considered in order to procure more effective ways to provide public and private assistance—MANAGED CARE IS NOT THE Reply!!! FOR-PROFIT HEALTH CARE IS NOT THE Respond! PRIVATIZATION IS NOT THE Reply!
References
Blumstein, J. F. (1996). Health care reform and competing visions of medical care: Antitrust and place provider cooperative legislation. Cornell Law Review,79,1459-1506.
Blumstein, J. F. (1996). The fraud and abuse statute in an evolving health care market Life in the health care speakeasy. American Journal of Law and Medicine,22(2), 205-231.
Bunis, D. (1996, July 16). Sweeping changes for health care: What it means to you. Long Island Newsday, pp. A6, A53.
Chartland, S. (1996, April 28). The changing game of health insurance. The Unique York Times [On-line. Available: http://www.ny€mes~com/
College of Physicians and Surgeons at Columbia-Presbyterian Medical Center Office of Public Relations. (1996, July 25) Press Release: Original York's Ivy League Medical Schools command first of its kind affiance.
Clymer, A. (1996, August 1). Accord reached on expanding worker's health benefits. The Modern York Times [On-line] Available: http://www.nytimes.com/yr/mo/day/pOlitic5/healthbffl.htmI
Consumer Reports. (1996, May 31). Children and health care.
Davis, K., & Shoen, (1996, March). Health services research and the changing health care system. Fresh York: The Commonwealth Fund. Available: http://www.cmwf.org
Donelan, K., Blendon, R. J. Hill, C.A., Hoffman, C., Rowland, D., Frankel, M., Altman, D. (1996). Whatever happened to the health insurance crisis in the United States? Journal of the American Medical Association,276(16), 1346-1350.
Durant, E.D. (1996). The Original York Health Reform Act of 1996: Costs of Exclusion. (Unpublished).
Employee Succor Research Institute. (1992). Sources of health insurance and characteristics of the uninsured. (Express Brief No. 123). Washington, DC. Available: http://www.ebri.org
Families USA (1996, July). HMO Consumers at risk: States to the rescue. Washington, DC: Families USA. Available: http://epn.org.families/farisk.html
Families USA (1996, June 7). New York managed care legislation: A model for other states. Washington, DC: Families USA. Available: http://epn.org/families/fastat.html
Families USA (1996, August). Kassebaum-Kennedy health insurance bill clears congress: Medicaid Saving Accounts shrimp to demonstration program. Washington, DC: Families USA. Available: http://epn.org/families/fakeka.html
Fein, E. B. (1996, July 5). For-profit hospitals: Once unthinkable, now probably inevitable. The Fresh York Times, [On-line]. Available: http://www.nytimes.com
Freudenheim, M. (1996, July 16). Grading becomes stricter on health plans. The Fresh York Times. [On-line]. Available: http://www.nytimes.com/sectionS/bUSiness
Health Care Portability and Accountability Act of 1996, Pub. L. No. 104-191 (1996).
Hoffman, C., Rice, D.R., & Sung, H.Y., (1996). Persons with chronic conditions: Their prevalence and costs. Journal of the American Medical Association,276,1473-1479.
Holusha, J. (1996, August18). For doctors togetherness is the unique blueprint of life. The Fresh York Times [On-line]. Available: http://www.nytimes.com/Cp960818.htfl1l
Levinson, M. (1996, June 26). As Blue Outrageous and Blue Shield head into the for-profit sector, it is helping to commence the biggest gold hurry since Sutter’s Mill. U.S.New [On-line]. Available: http:/ / www.usnews.com/
Levy, C. J. (1996, July 2). Original era in Modern York hospital-rate opinion. The Unique York Times, pp. Al.
Malpractice law evolves under managed care. Paper presented at the conference, Emerging Liability Issues in Managed Care, sponsored by the Robert Wood Johnson Foundation’s Improving Malpractice Prevention and Compensation Systems (IMPACS) program, October, 1995.
Market competition and the health care safety acquire. States of Health, (December, 1996) Washington, DC: Families USA. Available: http://epn.org/families/safeflet/html
Med-Access Search: Hospital Database. Available: http://medaccess.com/cgi/Hospital_basic.eXe
Metcalf, E. (1996, September 6). Columbia and Cornell belief alliance—2,800 physicians strong.. Columbia University Spectator, p.1.
Metcalf, E. (1996, September 27). Columbia/Cornell MD’s Ally. Columbia University Characterize, p. 1.
Nasr, H. (1996, July 31). Major university hospitals to merge. Columbia University Spectator, pp. 1,8.
Recent York Health Reform Act of 1996, NY AB 11330.
Pear, R. (1996, May 26). Two trends collide: The rise in proceed and of local HMOs. The Current York Times [On-line]. Available: http://www.nytimes.com
Perrin, E. C., Newacheck, P., Pless, B. I. Drotar, D., Gortmeaker, Steven, L., Leventhal, I., Perrin, J.M., Stein, R.E., Walker, D.E. Weitzman, M. (1993). Issues fervent in the definition and classification of chronic health conditions. Pediatrics, 91(4), 787-793.
Robert Wood Johnson Foundation (December 1995). HealthTracking: HMOs and US health care. Available: http://rwjf.org
Robert Wood Johnson Foundation (February 1995). Market consolidation, antitrust, and public policy in the health care industry: Agenda for future research. Prepared for the council on the economic impact of health care reform (item: HTO1).
Robert Wood Johnson Foundation (December 1995). Health Tracking: HMOs and US health care. Available: http://rwjf.org
Robert Wood Johnson Foundation (February 1995). Market consolidation, antitrust, and public policy in the health care industry: Agenda for future research. Prepared for the council on the economic impact of health care reform (item: HTO1).Robinson, R. (1993). Economic evaluation in health care: Cost-effectiveness analysis. [Education & Debate]. The British Medical Journal,307(6907), 793-795.
Robinson, R. (1993). Economic evaluation in health care: Cost-effectiveness analysis. [Education & Debate]. The British Medical Journal,307(6909), 924-926.
Rosenthal, E. (1996, July 2). Two more hospitals speed to join forces: Beth Israel-Long Island Jewish Merger to obtain far-flung empire. The Fresh York Times, p. B3.
Rosenthal, E. (1996, July 15). Patients say NY 1-IMOs don’t deal well with complex illnesses. The Unique York Times, p. Al.
Schiff, G. S. (1996, March 16). Managed care issues. Physicians for a National Health Notion. Available: pnhp@aol.com -
Selby, J. V., Fireman, B. H., & Swain, B.E. (1996). Conclude of a copayment on spend of the emergency department in a health maintenance organization. New England Journal of Medicine, 334,635-641.
Shaw, T. (1996, March 25). Dole’s awful medicine: health reform belief would raise costs, harm quality. USAToday, [On-line]. Distributed by the National Center for Policy Analysis.
Smolowe, J., Perman, S., & Van Tassel,J. (1996, April 15) A healthy merger? A vast deal makes Aetna the country’s largest health-care company. Time Magazine,14(16).
Spragins, E. (1996, September 24). Special Represent America’s best 1-IMOs: Rating the top managed care companies. Newsweek, pp.58-63.
Stone, D. A. (Monroe, J. A. & Beilcin, C. S. eds. 1994). The struggle for the soul of health insurance. The Politics of Health Care Reform,27-56.
Taylor, H. (1996, July 16). Health care capitalism remakes a city’s health system. The Albany Times [On-line]
Toim L (1996 July 31) Local 2110 loses its benefits Columbia University Spectator, pp 1-5
Van Duzer, K., & Nasr, H. (1996,July 31). Nurses reject final hospital’s offer, strike possible. Columbia University Spectator, pp. 1,8.
Ware, J.E., Bayliss, M.S., Rogers,W.H., Kosinski, M., Tarlov, A.R. (1996). Differences in 4-year health outcomes for elderly, awful, and chronically if patients treated in HMO and Fee-for-Service systems: Results invent a medical outcomes peer. Journal of the American Medical Association. L 1039-1047.
Williams, R. M. (1996). The cost of visits to emergency departments. New England Journal of Medicine, 334 642-646
Wines, M., & Pear, R. (1996, July 30). The President finds glean advantage from failure of health-care wretchedness. The Recent York Times [On-line]. Available: http://www.nytimes.cOm/web/dOcsroot/library/Politics/0730editon.html
Underwriting the Social Contract: Distributive Justice & Health Care Reform
The Quandary Statement
As health care costs climbed exponentially in the 1980’s, so did the cost of health insurance plans. As a result, employers began to enroll their employees in managed care organizations, and many Americans were forced to leave their veteran indemnity type plans. With the advent of the health maintenance organization, there is a financial incentive for the underutilization of care. (Blumstein, 1996; Davis & Shoen, 1996).
In order to gash financial risk, health insurance companies have restricted enrollment to individuals in terrible health. By covering the minimal standards of treatment and excluding high risk groups altogether, major US insurance companies have realized that the health insurance market can a be an extremely splendid 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.
Unique trend towards localized government leaves individuals without a financial safety derive. This is the least efficient manner to handle health care costs, and evades the premise that medical care is a natural just in a civilized society. Few Americans feel net within the fresh system. The rising costs of medical care contributed to the unusual market changes in both the administration and delivery of health services. The financial incentive to cloak only the healthiest individuals ignores the fact that medical care is a social helpful.
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 musty 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 derive 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 relieve the uninsured salvage a decent health policy, and then provides no solution to the well-known train 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 tell of greatest danger 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 appreciate footwork keen 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 valuable to identify the populations at risk for loosing health insurance coverage and the underinsured.
Kassebaum-Kennedy focuses on a slim allotment of the uninsured population, and those who would be eligible for COBRA continuation (Consolidated Omnibus Reconciliation Act of 1974). Of the 41 million uninsured Americans, only about 150,000 are expected to succor from this legislation. The Health Insurance Portability and Accountability Act of 1996 is really nothing more than smoke and mirrors since it fails to address the fair utter 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 unprejudiced require prescription medication. Cancer patients in remission may require chemotherapy, and a person suffering with a degenerative disease may be fervent in treatment studies. Each condition requires individualized treatment that cannot be based upon the simple economic/cost-benefit analysis old in the utilization review process by tremendous 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 raze all in progressive legislation, however, in actuality it will only serve about 150,000 people.
Fresh studies have found that the majority of the uninsured population simply cannot afford to pay the premiums (Donelan et. al., 1996; Hoffman & Rice, 1996). According to their data, only 1% of the Uninsured population is due to modern health position and exclusionary preexisting clauses, yet an overwhelming number of insured respondents reported an inability to receive medical care for chronic conditions. The majority of Americans with chronic illness are covered by some type of insurance, yet they are unexcited subject to the utilization review process and access problems that scream or delay medically famous treatment (Donelan, et. al., Hoffman & Rice, 1996).
Underwriting the Solidarity Principle
Worn forms of insurance underwriting required that the contract explicitly plot which illness or services are not covered by the policy, in reach. If the underwriter did not specifically area a definite 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 expend more services. Insurers began to require health explore station questionnaires (refer to attachment A), and even began implementing AIDS and genetic testing to identify high-risk individuals (Brunetta, as cited in Gutmann & Thompson, 1996). In the 1980s, gargantuan insurance companies began including sexual orientation as a high-risk category, by using actuarial sound criteria. Such criteria concluded that delighted men were a higher risk for contracting AIDS virus and refused to write policies for anyone believed to be homosexual, (Stone, 1994 as cited in Durant, 1996).
By limiting enrollment to the healthiest members of society, selective enrollment undermines the solidarity principle of health insurance (Davis & Shoen, 1996; Snow, 1996; Stone, 1994). By eliminating those who were suspect of using more services than their healthier counterparts expend, insurance companies are able to offer rock bottom prices for young, healthy individuals. By excluding preexisting conditions and requiring sure individuals to select 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 help as “wildcards” since they allow insurers to state 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 grunt 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 stout distinction between an individual being denied prescription medication at their local pharmacy due to a cost-effective formulary developed by their Managed Care Organizations (MCOs), than an individual being denied a liver transplant because healthy livers are a scarce resource. While both may have equally devastating consequences, it is more difficult to rationalize a lost life based upon rigid cost help analysis and utilization decisions made according to formulas and cost-benefit analysis of treatment protocols.
“The political controversy over the distribution of health care in the United States is an instructive spot in distributive justice. Well-behaved health is care is important for pursuing most other things in life. Yet equal access to health care would require the government to not only redistribute resources from the rich, healthy to the awful, and infirm, but also restrict the freedom of doctors and other health care providers. Such redistributions may be warranted, but to what level, and to what extent? ” Gutmann & Thompson (Page 178).
Blendon and his colleagues have reported similar findings in public belief polls from 1992 and 1994 (Blendon et. al., 1992; Blendon et. al., 1994). A current discover by the American Medical Association found cost to be of paramount pains to an overwhelming number of Americans (Donelan et. aI., 1996). Of the 40 million uninsured Americans, only 1% attributes their failure to glean health insurance coverage to their preexisting conditions. Among the uninsured, cost is cited as the well-known 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 idea 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 advance 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 pain 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 Modern York Daily News, 1996; Long Island Newsday, 1996; LA Times, 1996; Picayne Times, 1996; Columbia Spectator, 1996; Columbia University Picture, 1996; US News & World Reports, 1996; Newsweek 1996; Healthline, 1996; The Tennessean, 1996; The Albany Times, 1996; The Nashville Scene, 1996). In their entirety, these case reports recount the human tragedy that lies beneath the web of the very worst of American capitalism: corporate greed.
Identifying Populations At-Risk
A peek by The Lewison Group in 1996 reveals insight into the private individual health insurance market. Clearly, individuals choosing to recall health insurance policies for several hundred dollars each month inquire of their health care needs and expenditures to exceed that amount Regardless of health site, a young healthy 25 year frail 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 Heinous (based upon 1996 rates, novel rates available from the Unusual York Status Insurance Department).
Since individual policies are not addressed in the Health Insurance Portability and Accountability Act of 1996 (HIPA), an individual policy with Blue Unsuitable Blue Shield of Tennessee excludes preexisting conditions for 24 months (enrollment booklet available upon expect). The necessary 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 content or delay care for all services that are not outright medically primary. Growing numbers of individuals have suffered irreparable afflict, 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 grand evidence that individuals with chronic conditions receive snide care in HMOs.
A four-year longitudinal contemplate of medical outcomes found that the elderly, the terrible, and persons with chronic conditions were in better health when covered by fee-for-service plans compared with a control group covered in HMOs (Ware et. al., 1996). Unusual statistics released in Washington, DC by the American Medical Association and the Robert Wood Johnson Foundation revealed the pronounce costs of individuals with chronic conditions legend for 75% of pronounce 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 voice 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 speak medical expenditures, which means the millions of dollars being made by for-profit insurance companies are not being circulated into the economy to befriend in public health costs care. The industry made a 14.8% profit in the 3rd quarter of 1996, however these medical dollars were removed from health care and passe to fatten the pockets of CEO’s and majority stockholders (Healthline, 1996).
Based upon a unusual portray from the Robert Wood Johnson Foundation, the issue costs for persons with chronic conditions recount 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 Ogle 1987, not adjusted for inflation). This population is the most vulnerable to complications in their health and with their source of payment. Spacious 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 exquisite 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 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 situation courts for violations of the Medicaid Act (based upon a Lexis-Nexis search performed December 26, 1996). With the passing of H.R. 3507 into public law, (The Welfare Reform Bill) private citizens will secure dinky reprieve in the federal courts, so any attempts to believe states accountable for violations of federal law will be archaic 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 judge the public demands something more from physicians than to honest be a blob of bureaucrats, and I assume we have to remove a stand now and then. Our role essentially as patient advocate, is to yell them, well, objective because the insurance company is not going to pay, that is not the slay 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 Believe Kessler eloquently stated as she handed down her decision in Salazar v. District of Columbia, No. 93-452, December 11, 1996, “unhurried every fact found herein is a human face and the reality of being bad in the richest nation on earth, (936 F. Supp. Waddle op. At 3).
Perhaps most distressing is the lack of accountability for mismanaged healthcare and scandalous 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 spot courts. The Supreme Court of the United States has agreed to hear Unique York’s ask for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the position of Recent York.
When HMOs yelp 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 remove a serious watch at tort reform, and seek information from 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 residence 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 gape into the future of TennCare recipients and Medicaid beneficiaries in states around the country. Dating assist 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 definite,” (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 well-behaved of comment is that Arizona is the only site to have voted Republican in every election since 1948—certainly provides insight into the conservative morale of the residence. Although Arizona was the last set to gather the Medicaid cost sharing incentive proposed by the federal government in 1966, it was the first situation to force its medically indigent population into managed care in 1981.
Violating Federal Law
Rigid pre-certification requirements and nonspecific utilization review procedures region strategic barriers to access medical treatment and services in Health Maintenance Organizations (HMOs). Pre-certification requirements are strategic barriers incorporated into the “shaded box” of utilization review that institutionalizes exclusionary waiting periods and routine denials of medically critical treatment. According to federal law, “care and services are to be provided in a manner consistent with the simplicity of administration and the best interests of recipients,” (42 U.S.C. § I 396a (a) (19)). Clearly, such rigid pre-certification requirements that complicate administrative processing and paperwork on the allotment of the enrolled beneficiaries is a violation of United States Code.
Furthermore, using principal care providers as a mechanism to limit access to specialists not only complicates administrative processing, but limits enrolled beneficiaries choice of health professionals beyond what is available to the general public in the geographic state (42 U.S.C. § 1 396a (a)(30)(A)). Certainly referral procedures do not “sigh 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 resolve 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 runt to no knowledge specific to the medical management of degenerative
Under the Medicaid Act of 1966, covered beneficiaries may appeal any utilization review decision which denies care or limits services. The Medicaid Act gives individuals the accurate to a radiant hearing in front of an honest independent Medical Review Unit (MRU). Furthermore, the Medicaid Act clearly states that medical services for a Medicaid beneficiary may not be terminated until the said beneficiary receives such a hearing
Conclusion
The country as a whole must realize what 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 steady people to whom this bloodless language gives voice: anxious working parents who are too terrible to fetch medications or heart catheter procedures or lead poisoning screening for their children, AIDS patients unable to obtain treatment, elderly persons suffering from chronic conditions like diabetes and heart disease who require constant monitoring arid medical attention. Tedious every fact found herein is a human face and the reality of being bad in the richest nation on earth. (Pace 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 trustworthy 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 piece of the general public is unable to secure health insurance coverage due to a preexisting condition, the more notable reveal remains the cost of coverage. The cost of medical care will remain an protest since fresh legislative efforts evade the explain. Unique changes in the delivery of health services is of grave misfortune and different options must be considered in order to procure more effective ways to provide public and private assistance—MANAGED CARE IS NOT THE Retort!!! FOR-PROFIT HEALTH CARE IS NOT THE Retort! PRIVATIZATION IS NOT THE Retort!
References
Blumstein, J. F. (1996). Health care reform and competing visions of medical care: Antitrust and residence provider cooperative legislation. Cornell Law Review,79,1459-1506.
Blumstein, J. F. (1996). The fraud and abuse statute in an evolving health care market Life in the health care speakeasy. American Journal of Law and Medicine,22(2), 205-231.
Bunis, D. (1996, July 16). Sweeping changes for health care: What it means to you. Long Island Newsday, pp. A6, A53.
Chartland, S. (1996, April 28). The changing game of health insurance. The Unique York Times [On-line. Available: http://www.ny€mes~com/
College of Physicians and Surgeons at Columbia-Presbyterian Medical Center Office of Public Relations. (1996, July 25) Press Release: Unusual York's Ivy League Medical Schools yell first of its kind affiance.
Clymer, A. (1996, August 1). Accord reached on expanding worker's health benefits. The Unusual York Times [On-line] Available: http://www.nytimes.com/yr/mo/day/pOlitic5/healthbffl.htmI
Consumer Reports. (1996, May 31). Children and health care.
Davis, K., & Shoen, (1996, March). Health services research and the changing health care system. Original York: The Commonwealth Fund. Available: http://www.cmwf.org
Donelan, K., Blendon, R. J. Hill, C.A., Hoffman, C., Rowland, D., Frankel, M., Altman, D. (1996). Whatever happened to the health insurance crisis in the United States? Journal of the American Medical Association,276(16), 1346-1350.
Durant, E.D. (1996). The Novel York Health Reform Act of 1996: Costs of Exclusion. (Unpublished).
Employee Wait On Research Institute. (1992). Sources of health insurance and characteristics of the uninsured. (Say Brief No. 123). Washington, DC. Available: http://www.ebri.org
Families USA (1996, July). HMO Consumers at risk: States to the rescue. Washington, DC: Families USA. Available: http://epn.org.families/farisk.html
Families USA (1996, June 7). New York managed care legislation: A model for other states. Washington, DC: Families USA. Available: http://epn.org/families/fastat.html
Families USA (1996, August). Kassebaum-Kennedy health insurance bill clears congress: Medicaid Saving Accounts tiny to demonstration program. Washington, DC: Families USA. Available: http://epn.org/families/fakeka.html
Fein, E. B. (1996, July 5). For-profit hospitals: Once unthinkable, now probably inevitable. The Unique York Times, [On-line]. Available: http://www.nytimes.com
Freudenheim, M. (1996, July 16). Grading becomes stricter on health plans. The Recent York Times. [On-line]. Available: http://www.nytimes.com/sectionS/bUSiness
Health Care Portability and Accountability Act of 1996, Pub. L. No. 104-191 (1996).
Hoffman, C., Rice, D.R., & Sung, H.Y., (1996). Persons with chronic conditions: Their prevalence and costs. Journal of the American Medical Association,276,1473-1479.
Holusha, J. (1996, August18). For doctors togetherness is the novel map of life. The Current York Times [On-line]. Available: http://www.nytimes.com/Cp960818.htfl1l
Levinson, M. (1996, June 26). As Blue Tainted and Blue Shield head into the for-profit sector, it is helping to begin the biggest gold race since Sutter’s Mill. U.S.New [On-line]. Available: http:/ / www.usnews.com/
Levy, C. J. (1996, July 2). Unusual era in Current York hospital-rate opinion. The Unique York Times, pp. Al.
Malpractice law evolves under managed care. Paper presented at the conference, Emerging Liability Issues in Managed Care, sponsored by the Robert Wood Johnson Foundation’s Improving Malpractice Prevention and Compensation Systems (IMPACS) program, October, 1995.
Market competition and the health care safety regain. States of Health, (December, 1996) Washington, DC: Families USA. Available: http://epn.org/families/safeflet/html
Med-Access Search: Hospital Database. Available: http://medaccess.com/cgi/Hospital_basic.eXe
Metcalf, E. (1996, September 6). Columbia and Cornell concept alliance—2,800 physicians strong.. Columbia University Spectator, p.1.
Metcalf, E. (1996, September 27). Columbia/Cornell MD’s Ally. Columbia University Describe, p. 1.
Nasr, H. (1996, July 31). Major university hospitals to merge. Columbia University Spectator, pp. 1,8.
Recent York Health Reform Act of 1996, NY AB 11330.
Pear, R. (1996, May 26). Two trends collide: The rise in go and of local HMOs. The Current York Times [On-line]. Available: http://www.nytimes.com
Perrin, E. C., Newacheck, P., Pless, B. I. Drotar, D., Gortmeaker, Steven, L., Leventhal, I., Perrin, J.M., Stein, R.E., Walker, D.E. Weitzman, M. (1993). Issues alive to in the definition and classification of chronic health conditions. Pediatrics, 91(4), 787-793.
Robert Wood Johnson Foundation (December 1995). HealthTracking: HMOs and US health care. Available: http://rwjf.org
Robert Wood Johnson Foundation (February 1995). Market consolidation, antitrust, and public policy in the health care industry: Agenda for future research. Prepared for the council on the economic impact of health care reform (item: HTO1).
Robert Wood Johnson Foundation (December 1995). Health Tracking: HMOs and US health care. Available: http://rwjf.org
Robert Wood Johnson Foundation (February 1995). Market consolidation, antitrust, and public policy in the health care industry: Agenda for future research. Prepared for the council on the economic impact of health care reform (item: HTO1).Robinson, R. (1993). Economic evaluation in health care: Cost-effectiveness analysis. [Education & Debate]. The British Medical Journal,307(6907), 793-795.
Robinson, R. (1993). Economic evaluation in health care: Cost-effectiveness analysis. [Education & Debate]. The British Medical Journal,307(6909), 924-926.
Rosenthal, E. (1996, July 2). Two more hospitals speed to join forces: Beth Israel-Long Island Jewish Merger to obtain far-flung empire. The Modern York Times, p. B3.
Rosenthal, E. (1996, July 15). Patients say NY 1-IMOs don’t deal well with complex illnesses. The Unusual York Times, p. Al.
Schiff, G. S. (1996, March 16). Managed care issues. Physicians for a National Health Belief. Available: pnhp@aol.com -
Selby, J. V., Fireman, B. H., & Swain, B.E. (1996). Finish of a copayment on spend of the emergency department in a health maintenance organization. New England Journal of Medicine, 334,635-641.
Shaw, T. (1996, March 25). Dole’s terrible medicine: health reform view would raise costs, distress quality. USAToday, [On-line]. Distributed by the National Center for Policy Analysis.
Smolowe, J., Perman, S., & Van Tassel,J. (1996, April 15) A healthy merger? A tremendous deal makes Aetna the country’s largest health-care company. Time Magazine,14(16).
Spragins, E. (1996, September 24). Special Describe America’s best 1-IMOs: Rating the top managed care companies. Newsweek, pp.58-63.
Stone, D. A. (Monroe, J. A. & Beilcin, C. S. eds. 1994). The struggle for the soul of health insurance. The Politics of Health Care Reform,27-56.
Taylor, H. (1996, July 16). Health care capitalism remakes a city’s health system. The Albany Times [On-line]
Toim L (1996 July 31) Local 2110 loses its benefits Columbia University Spectator, pp 1-5
Van Duzer, K., & Nasr, H. (1996,July 31). Nurses reject final hospital’s offer, strike possible. Columbia University Spectator, pp. 1,8.
Ware, J.E., Bayliss, M.S., Rogers,W.H., Kosinski, M., Tarlov, A.R. (1996). Differences in 4-year health outcomes for elderly, bad, and chronically if patients treated in HMO and Fee-for-Service systems: Results get a medical outcomes view. Journal of the American Medical Association. L 1039-1047.
Williams, R. M. (1996). The cost of visits to emergency departments. New England Journal of Medicine, 334 642-646
Wines, M., & Pear, R. (1996, July 30). The President finds collect advantage from failure of health-care peril. The Current York Times [On-line]. Available: http://www.nytimes.cOm/web/dOcsroot/library/Politics/0730editon.html
