Distributive Justice and Health Care Reform

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 mature indemnity type plans. With the advent of the health maintenance organization, there is a financial incentive for the underutilization of care. (Blumstein, 1996; Davis & Shoen, 1996).

In order to slice financial risk, health insurance companies have restricted enrollment to individuals in bad health. By covering the minimal standards of treatment and excluding high risk groups altogether, major US insurance companies have realized that the health insurance market can a be an extremely 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 determined 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 score. This is the least efficient manner to handle health care costs, and evades the premise that medical care is a natural good in a civilized society. Few Americans feel catch within the modern system. The rising costs of medical care contributed to the modern market changes in both the administration and delivery of health services. The financial incentive to hide only the healthiest individuals ignores the fact that medical care is a social genuine.

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 conventional 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 wait on an estimated 150,000 Americans accumulate 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 worry for those at risk for losing their health insurance. It does nothing to back the uninsured win a decent health policy, and then provides no solution to the valuable protest 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 scream of greatest danger to the citizens of this country: the cost of medical care. The Bill looks towards the states to execute consumer protections and weakens the regulatory role of the federal government. The majority of the American public is unaware of the adore 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 essential 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 support from this legislation. The Health Insurance Portability and Accountability Act of 1996 is really nothing more than smoke and mirrors since it fails to address the upright allege at hand—the simple fact that the cost of quality health care in America is becoming a privilege that only the wealthy can afford.

The Cost of Care for Pre-existing Conditions

An individual with high blood pressure may objective require prescription medication. Cancer patients in remission may require chemotherapy, and a person suffering with a degenerative disease may be keen in treatment studies. Each condition requires individualized treatment that cannot be based upon the simple economic/cost-benefit analysis faded in the utilization review process by substantial insurance companies. Clearly, the most effective treatment for one patient may not be the best for another. The time required for utilization review may expose additional health risks and complications to a patient suffering from a chronic health condition.

Twelve months without insurance coverage may be financially devastating to some patients, and 63% of Americans have already forgone some type of medical treatment within the last year due to financial constraints. Publicity surrounding Kennedy-Kassebaum has hailed the bill as the “be all and extinguish all in progressive legislation, however, in actuality it will only back 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 novel health state and exclusionary preexisting clauses, yet an overwhelming number of insured respondents reported an inability to receive medical care for chronic conditions. The majority of Americans with chronic illness are covered by some type of insurance, yet they are quiet subject to the utilization review process and access problems that teach or delay medically indispensable treatment (Donelan, et. al., Hoffman & Rice, 1996).

Underwriting the Solidarity Principle

Used forms of insurance underwriting required that the contract explicitly spot which illness or services are not covered by the policy, in approach. If the underwriter did not specifically position a sure condition in the contract, the insurer was held to the terms of the contract and required to pay for services utilized by the policyholder (Stone, 1994, as cited in Durant, 1996).

Increasing numbers of for-profit and non-profit insurance companies began to control costs by refusing to insure individuals who they felt would exhaust more services. Insurers began to require health gaze 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, broad insurance companies began including sexual orientation as a high-risk category, by using actuarial sound criteria. Such criteria concluded that cheerful 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 utilize, insurance companies are able to offer rock bottom prices for young, healthy individuals. By excluding preexisting conditions and requiring distinct individuals to take high-risk policies, the number of uninsured and underinsured Americans continues to grow exponentially (Durant, 1996).

More individuals are choosing not to rob insurance simply because they cannot afford it. Even among those with employer based health coverage, the policies frequently exclude coverage for long-term illness or care of chronic conditions (MSNBC News Forum, 1996). Without a standard definition of preexisting conditions, these clauses abet as “wildcards” since they allow insurers to impart 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 negate 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 mammoth 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 attend analysis and utilization decisions made according to formulas and cost-benefit analysis of treatment protocols.

“The political controversy over the distribution of health care in the United States is an instructive scrape in distributive justice. Capable health is care is distinguished for pursuing most other things in life. Yet equal access to health care would require the government to not only redistribute resources from the rich, healthy to the bad, 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 concept polls from 1992 and 1994 (Blendon et. al., 1992; Blendon et. al., 1994). A new view 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 score 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 belief polls prove the legitimate role and public desire for government regulation of the health care industry. It has become distinct that the federal government must intervene in order to protect natural law rights, the social contract, and the Constitution of the United States. Regulation is needed to protect the individual freedoms, liberty, and the pursuit of “health, happiness, and the American Dream.”

If America is to be the “Land of Opportunity,” then clearly individual health and wellness should be an ideal to approach for. Unique models of distributive justice emphasize public consensus as a legitimate role for government intervention. According to a number of studies by Blendon and his colleagues, the public has reported an overwhelming general worry 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 Describe, 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 explore by The Lewison Group in 1996 reveals insight into the private individual health insurance market. Clearly, individuals choosing to acquire health insurance policies for several hundred dollars each month question their health care needs and expenditures to exceed that amount Regardless of health place, a young healthy 25 year obsolete 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 Base (based upon 1996 rates, unusual 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 demand). The famous markets in need of reform are the adversely selected individual insurance market, and the state’s most vulnerable populations: children; the elderly; the chronically ill; the uninsured; and the underinsured.

For the millions of individuals who have lost their employer based coverage, the cost of private health insurance is prohibitively expensive. Many individuals opt out of the individual market and apply for public assistance when the need arises. Those who have retained their health insurance coverage through their employers are being moved into managed care despite their efforts to preserve their indemnity style plans (Davis & Shoen, 1996; The Lewison Group, 1996).

Access to Medical Care

As routine practice, HMOs stutter or delay care for all services that are not outright medically famous. Growing numbers of individuals have suffered irreparable hurt, 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 big evidence that individuals with chronic conditions receive obnoxious care in HMOs.

A four-year longitudinal inspect of medical outcomes found that the elderly, the unpleasant, and persons with chronic conditions were in better health when covered by fee-for-service plans compared with a control group covered in HMOs (Ware et. al., 1996). Unique statistics released in Washington, DC by the American Medical Association and the Robert Wood Johnson Foundation revealed the assure costs of individuals with chronic conditions tale for 75% of mumble 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 pronounce 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 philosophize medical expenditures, which means the millions of dollars being made by for-profit insurance companies are not being circulated into the economy to back in public health costs care. The industry made a 14.8% profit in the 3rd quarter of 1996, however these medical dollars were removed from health care and mature to fatten the pockets of CEO’s and majority stockholders (Healthline, 1996).

Based upon a recent represent from the Robert Wood Johnson Foundation, the stutter costs for persons with chronic conditions characterize 69.4% of national expenditures in personal health care (Robert Wood Johnson Foundation, 1996). Their explain 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 Spy 1987, not adjusted for inflation). This population is the most vulnerable to complications in their health and with their source of payment. Big insurance companies only provide adequate coverage for acute illness (Donelan et al., 1996; Hoffman et. al, 1996).

Medicaid Managed Care

Following Tennessee’s lead, many states have enrolled their medically indigent populations in Medicaid Managed Care Organizations (MCOs). In Daniels v. Wadley, (926 F. Supp. 1305), the court held that TennCare violated the Due Process Clause of the Fourteenth Amendment since such procedures eliminate delicate 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 quandary 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 location courts for violations of the Medicaid Act (based upon a Lexis-Nexis search performed December 26, 1996). With the passing of H.R. 3507 into public law, (The Welfare Reform Bill) private citizens will come by puny reprieve in the federal courts, so any attempts to enjoy states accountable for violations of federal law will be outmoded 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 plot of Arizona commented in 1981, “We play sort of an advocacy role. I assume the public demands something more from physicians than to unprejudiced be a blob of bureaucrats, and I contemplate we have to pick a stand now and then. Our role essentially as patient advocate, is to snarl 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 Think Kessler eloquently stated as she handed down her decision in Salazar v. District of Columbia, No. 93-452, December 11, 1996, “tedious every fact found herein is a human face and the reality of being abominable in the richest nation on earth, (936 F. Supp. Lope op. At 3).

Perhaps most distressing is the lack of accountability for mismanaged healthcare and inferior 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 notable human resources as we await decisions to be handed down from dwelling courts. The Supreme Court of the United States has agreed to hear Unusual York’s quiz for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the spot of Novel York.

When HMOs bid care from patients, it is ludicrous to maintain individual physicians liable for the utilization decisions made by decentralized corporate review boards. It is time to occupy a serious inspect at tort reform, and ask action by the Supreme Court as they near the date of Original 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 spot courts. The court must uphold Daniels v. Wadley, and Salazar v. District of Columbia if further lives are to be saved in medicine rather than wasted away in the utilization review procedures. While we wait patiently for District of Columbia circuit court to order injunctive relief, the number of individuals suffering irreparable injure due to the systematic denial of medical care grows larger each day.

The history of Medicaid Managed Care does not provide a very optimistic ogle into the future of TennCare recipients and Medicaid beneficiaries in states around the country. Dating support 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 pains.

Perhaps profitable 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 location. Although Arizona was the last site to come by 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 “dusky 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 fraction of the enrolled beneficiaries is a violation of United States Code.

Furthermore, using considerable care providers as a mechanism to limit access to specialists not only complicates administrative processing, but limits enrolled beneficiaries choice of health professionals beyond what is available to the general public in the geographic set (42 U.S.C. § 1 396a (a)(30)(A)). Certainly referral procedures do not “voice that recipients will have their choice of health professionals within the conception to the extent possible and appropriate,” (42 U.S.C. § 434.29). Under this provision, it seems that any individual, especially those with chronic health conditions or disabilities should be allowed to resolve a vital care provider with more expertise than a nurse practitioner. I will argue that a neurologist is more familiar with the unusual needs of a patient with Multiple Sclerosis than a nurse practitioner is with tiny to no knowledge specific to the medical management of degenerative

Under the Medicaid Act of 1966, covered beneficiaries may appeal any utilization review decision which denies care or limits services. The Medicaid Act gives individuals the true to a splendid hearing in front of an objective independent Medical Review Unit (MRU). Furthermore, the Medicaid Act clearly states that medical services for a Medicaid beneficiary may not be terminated until the said beneficiary receives such a hearing

Conclusion

The country as a whole must realize what Contemplate Kessler told her courtroom. Her words are certainly words I will not forget—certainly worth being quoted at length:

“This case is about people—children and adults who are sick, 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 proper people to whom this bloodless language gives voice: anxious working parents who are too abominable to catch medications or heart catheter procedures or lead poisoning screening for their children, AIDS patients unable to pick up treatment, elderly persons suffering from chronic conditions like diabetes and heart disease who require constant monitoring arid medical attention. Unhurried every fact found herein is a human face and the reality of being awful in the richest nation on earth. (Hasten 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 capable has removed millions of dollars from the healthcare marketplace with “medical loss ratios” of 57% compared to 85% in the outmoded health insurance market

Although a slim part of the general public is unable to accumulate health insurance coverage due to a preexisting condition, the more significant yell remains the cost of coverage. The cost of medical care will remain an order since novel legislative efforts evade the announce. Novel changes in the delivery of health services is of grave grief and different options must be considered in order to acquire more effective ways to provide public and private assistance—MANAGED CARE IS NOT THE Retort!!! FOR-PROFIT HEALTH CARE IS NOT THE Respond! PRIVATIZATION IS NOT THE Acknowledge!

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Underwriting the Social Contract: Distributive Justice & Health Care Reform

The Predicament 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 used 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 cleave 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 estimable industry. The public sector absorbs the cost of unreimbursed care for chronic care in America (Robert Wood Johnson Foundation, 1996). Based upon these findings, it seems definite that the money being removed from the health care marketplace is fattening the pockets of CEOs and majority stockholders.

Unusual trend towards localized government leaves individuals without a financial safety fetch. 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 obtain within the unusual 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 shroud only the healthiest individuals ignores the fact that medical care is a social generous.

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 former 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 aid an estimated 150,000 Americans gain 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 disaster for those at risk for losing their health insurance. It does nothing to serve the uninsured gather a decent health policy, and then provides no solution to the principal inform 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 order of greatest anguish to the citizens of this country: the cost of medical care. The Bill looks towards the states to acquire consumer protections and weakens the regulatory role of the federal government. The majority of the American public is unaware of the adore footwork fervent with this legislation, and the demographics of the population it is intended to protect. In order to assess the utility of this Bill, it is primary 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 help 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 deliver 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 honest require prescription medication. Cancer patients in remission may require chemotherapy, and a person suffering with a degenerative disease may be alive to in treatment studies. Each condition requires individualized treatment that cannot be based upon the simple economic/cost-benefit analysis primitive in the utilization review process by ample insurance companies. Clearly, the most effective treatment for one patient may not be the best for another. The time required for utilization review may prove additional health risks and complications to a patient suffering from a chronic health condition.

Twelve months without insurance coverage may be financially devastating to some patients, and 63% of Americans have already forgone some type of medical treatment within the last year due to financial constraints. Publicity surrounding Kennedy-Kassebaum has hailed the bill as the “be all and ruin all in progressive legislation, however, in actuality it will only abet about 150,000 people.

Unique 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 plot and exclusionary preexisting clauses, yet an overwhelming number of insured respondents reported an inability to receive medical care for chronic conditions. The majority of Americans with chronic illness are covered by some type of insurance, yet they are peaceful subject to the utilization review process and access problems that express or delay medically valuable treatment (Donelan, et. al., Hoffman & Rice, 1996).

Underwriting the Solidarity Principle

Aged forms of insurance underwriting required that the contract explicitly region which illness or services are not covered by the policy, in come. If the underwriter did not specifically plot a sure condition in the contract, the insurer was held to the terms of the contract and required to pay for services utilized by the policyholder (Stone, 1994, as cited in Durant, 1996).

Increasing numbers of for-profit and non-profit insurance companies began to control costs by refusing to insure individuals who they felt would use more services. Insurers began to require health inspect state 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, mountainous insurance companies began including sexual orientation as a high-risk category, by using actuarial sound criteria. Such criteria concluded that overjoyed men were a higher risk for contracting AIDS virus and refused to write policies for anyone believed to be homosexual, (Stone, 1994 as cited in Durant, 1996).

By limiting enrollment to the healthiest members of society, selective enrollment undermines the solidarity principle of health insurance (Davis & Shoen, 1996; Snow, 1996; Stone, 1994). By eliminating those who were suspect of using more services than their healthier counterparts employ, insurance companies are able to offer rock bottom prices for young, healthy individuals. By excluding preexisting conditions and requiring positive individuals to catch high-risk policies, the number of uninsured and underinsured Americans continues to grow exponentially (Durant, 1996).

More individuals are choosing not to engage insurance simply because they cannot afford it. Even among those with employer based health coverage, the policies frequently exclude coverage for long-term illness or care of chronic conditions (MSNBC News Forum, 1996). Without a standard definition of preexisting conditions, these clauses succor as “wildcards” since they allow insurers to yell 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 speak treatment for benefits and services for the policyholder for undiagnosed illnesses or conditions of which they were unaware. As a result, the insurers began to inquire of 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 tremendous distinction between an individual being denied prescription medication at their local pharmacy due to a cost-effective formulary developed by their Managed Care Organizations (MCOs), than an individual being denied a liver transplant because healthy livers are a scarce resource. While both may have equally devastating consequences, it is more difficult to rationalize a lost life based upon rigid cost serve analysis and utilization decisions made according to formulas and cost-benefit analysis of treatment protocols.

“The political controversy over the distribution of health care in the United States is an instructive quandary in distributive justice. Grand health is care is essential 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 bad, 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 understanding polls from 1992 and 1994 (Blendon et. al., 1992; Blendon et. al., 1994). A modern search for 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 earn 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 notion polls explain the legitimate role and public desire for government regulation of the health care industry. It has become definite that the federal government must intervene in order to protect natural law rights, the social contract, and the Constitution of the United States. Regulation is needed to protect the individual freedoms, liberty, and the pursuit of “health, happiness, and the American Dream.”

If America is to be the “Land of Opportunity,” then clearly individual health and wellness should be an ideal to approach 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 anxiety about health care in this country, (1992, 1993, 1994, 1995, 1996).

Region civil courts are backed up with cases where HMOs have violated the First Amendment (gag orders), the Fourteenth Amendment (due process), and the rights of protected classes under the Americans with Disabilities Act. Countless examples of “anecdotal” evidence appear as headlines everyday across the country. (Novel York Times, 1996; The Modern York Daily News, 1996; Long Island Newsday, 1996; LA Times, 1996; Picayne Times, 1996; Columbia Spectator, 1996; Columbia University 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 characterize the human tragedy that lies beneath the web of the very worst of American capitalism: corporate greed.

Identifying Populations At-Risk

A sight by The Lewison Group in 1996 reveals insight into the private individual health insurance market. Clearly, individuals choosing to assume health insurance policies for several hundred dollars each month quiz their health care needs and expenditures to exceed that amount Regardless of health location, a young healthy 25 year venerable who purchases an individual health insurance policy can seek information from to pay well over $300.00 monthly for a health insurance policy with Empire Blue Shield Blue Sinful (based upon 1996 rates, unique rates available from the Modern York Area Insurance Department).

Since individual policies are not addressed in the Health Insurance Portability and Accountability Act of 1996 (HIPA), an individual policy with Blue Unfavorable Blue Shield of Tennessee excludes preexisting conditions for 24 months (enrollment booklet available upon quiz). The distinguished markets in need of reform are the adversely selected individual insurance market, and the state’s most vulnerable populations: children; the elderly; the chronically ill; the uninsured; and the underinsured.

For the millions of individuals who have lost their employer based coverage, the cost of private health insurance is prohibitively expensive. Many individuals opt out of the individual market and apply for public assistance when the need arises. Those who have retained their health insurance coverage through their employers are being moved into managed care despite their efforts to preserve their indemnity style plans (Davis & Shoen, 1996; The Lewison Group, 1996).

Access to Medical Care

As routine practice, HMOs scream or delay care for all services that are not outright medically valuable. Growing numbers of individuals have suffered irreparable distress, and many have died awaiting approval from their HMO’s (The Unusual York Times, 1996; Long Island Newsday, 1996; The Tennessean, 1996; Healthline, 1996). It is hardly a secret that HMOs have fallen short of their promise to provide comprehensive health care for the “whole” individual by emphasizing preventative medicine, using medical management to coordinate care. There is great evidence that individuals with chronic conditions receive execrable care in HMOs.

A four-year longitudinal glimpse of medical outcomes found that the elderly, the dreadful, and persons with chronic conditions were in better health when covered by fee-for-service plans compared with a control group covered in HMOs (Ware et. al., 1996). Fresh statistics released in Washington, DC by the American Medical Association and the Robert Wood Johnson Foundation revealed the relate costs of individuals with chronic conditions memoir for 75% of explain 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 narrate 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 say medical expenditures, which means the millions of dollars being made by for-profit insurance companies are not being circulated into the economy to support 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 aged to fatten the pockets of CEO’s and majority stockholders (Healthline, 1996).

Based upon a recent characterize from the Robert Wood Johnson Foundation, the snarl costs for persons with chronic conditions describe 69.4% of national expenditures in personal health care (Robert Wood Johnson Foundation, 1996). Their assure 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. 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 handsome 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 area courts for violations of the Medicaid Act (based upon a Lexis-Nexis search performed December 26, 1996). With the passing of H.R. 3507 into public law, (The Welfare Reform Bill) private citizens will accumulate microscopic reprieve in the federal courts, so any attempts to contain states accountable for violations of federal law will be old-fashioned at best (Denkeret. al., 1996).

Managed care has shown itself to be a farce of “medical management” in light of all the condemning evidence to the contrary. Timothy Icenogle, a medical doctor in the station of Arizona commented in 1981, “We play sort of an advocacy role. I consider the public demands something more from physicians than to impartial be a blob of bureaucrats, and I believe we have to select a stand now and then. Our role essentially as patient advocate, is to screech them, well, objective because the insurance company is not going to pay, that is not the raze 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 Deem 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 bad in the richest nation on earth, (936 F. Supp. Pace op. At 3).

Perhaps most distressing is the lack of accountability for mismanaged healthcare and immoral denials of medically valuable treatment. HMOs claim immunity under ERISA, and leaving individuals without recourse in a sea contractual language and lengthy court calendars. It is evident that individuals protected under the Medicaid Act are not fundamentally different from other populations entrapped in the maze of managed care. They are simply those who have “had their day in court.”

Due Process Protections

Since all Americans are theoretically entitled to due process protections under the constitution of the United States, it seems the federal courts are long overdue for making such a public statement. We are wasting precious time and losing millions in considerable human resources as we await decisions to be handed down from position courts. The Supreme Court of the United States has agreed to hear Modern York’s ask for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the station of Unique York.

When HMOs sing care from patients, it is ludicrous to have individual physicians liable for the utilization decisions made by decentralized corporate review boards. It is time to assume a serious survey at tort reform, and put a question to action by the Supreme Court as they near 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 station 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 afflict due to the systematic denial of medical care grows larger each day.

The history of Medicaid Managed Care does not provide a very optimistic glance into the future of TennCare recipients and Medicaid beneficiaries in states around the country. Dating support to the implementation of the Arizona Health Care Cost Containment System (AHCCCS) in 1981, there are documented cases where “people reportedly died for lack of medical treatment before their eligibility was clear,” (Varley, as cited in Gutman & Thompson, I 996). This leaves me to wonder why the states continue to enroll their most vulnerable populations into a system of managed care that has proven to be a difficulty.

Perhaps pleasurable of comment is that Arizona is the only place to have voted Republican in every election since 1948—certainly provides insight into the conservative morale of the set. Although Arizona was the last situation to secure the Medicaid cost sharing incentive proposed by the federal government in 1966, it was the first area to force its medically indigent population into managed care in 1981.

Violating Federal Law

Rigid pre-certification requirements and nonspecific utilization review procedures set strategic barriers to access medical treatment and services in Health Maintenance Organizations (HMOs). Pre-certification requirements are strategic barriers incorporated into the “dismal box” of utilization review that institutionalizes exclusionary waiting periods and routine denials of medically notable treatment. According to federal law, “care and services are to be provided in a manner consistent with the simplicity of administration and the best interests of recipients,” (42 U.S.C. § I 396a (a) (19)). Clearly, such rigid pre-certification requirements that complicate administrative processing and paperwork on the fragment of the enrolled beneficiaries is a violation of United States Code.

Furthermore, using valuable 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 station (42 U.S.C. § 1 396a (a)(30)(A)). Certainly referral procedures do not “inform that recipients will have their choice of health professionals within the opinion to the extent possible and appropriate,” (42 U.S.C. § 434.29). Under this provision, it seems that any individual, especially those with chronic health conditions or disabilities should be allowed to decide a valuable care provider with more expertise than a nurse practitioner. I will argue that a neurologist is more familiar with the new needs of a patient with Multiple Sclerosis than a nurse practitioner is with 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 apt to a pretty 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 Think Kessler told her courtroom. Her words are certainly words I will not forget—certainly worth being quoted at length:

“This case is about people—children and adults who are sick, terrible, and vulnerable—for whom life, in the memorable words of poet Langston Hughes, “ain’t been no crystal stair”. It is written in the dry and bloodless language of “the Iaw”—statistics, acronyms of agencies and bureaucratic entities, Supreme Court case names and quotes, official governmental reports, periodicity tables, etc. But let there be no forgetting the loyal people to whom this bloodless language gives voice: anxious working parents who are too abominable to accept medications or heart catheter procedures or lead poisoning screening for their children, AIDS patients unable to fetch treatment, elderly persons suffering from chronic conditions like diabetes and heart disease who require constant monitoring arid medical attention. Leisurely every fact found herein is a human face and the reality of being unpleasant in the richest nation on earth. (Dash 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 grand 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 rep health insurance coverage due to a preexisting condition, the more well-known protest remains the cost of coverage. The cost of medical care will remain an screech since unusual legislative efforts evade the voice. Fresh changes in the delivery of health services is of grave peril and different options must be considered in order to net more effective ways to provide public and private assistance—MANAGED CARE IS NOT THE Respond!!! FOR-PROFIT HEALTH CARE IS NOT THE Reply! PRIVATIZATION IS NOT THE Reply!

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