Underwriting the Social Contract: Distributive Justice & Health Care Reform
The Jam 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 primitive indemnity type plans. With the advent of the health maintenance organization, there is a financial incentive for the underutilization of care. (Blumstein, 1996; Davis & Shoen, 1996).
In order to slice financial risk, health insurance companies have restricted enrollment to individuals in dreadful health. By covering the minimal standards of treatment and excluding high risk groups altogether, major US insurance companies have realized that the health insurance market can a be an extremely gracious 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.
Modern trend towards localized government leaves individuals without a financial safety regain. This is the least efficient manner to handle health care costs, and evades the premise that medical care is a natural lawful in a civilized society. Few Americans feel fetch within the unusual system. The rising costs of medical care contributed to the current market changes in both the administration and delivery of health services. The financial incentive to conceal only the healthiest individuals ignores the fact that medical care is a social pleasurable.
Health Insurance Portability Act of 1996
Two years after the Clinton Health View was defeated in Congress, Senator Ted Kennedy and Nancy Kassebaum introduced the Kennedy-Kassebaum Bill in response to growing concerns about selective enrollment procedures passe by health insurance companies in the private sector. In the final version of the Bill, insurance companies must limit preexisting condition clauses to twelve months. It has been estimated that this provision of the Bill will benefit an estimated 150,000 Americans come by health insurance coverage.
There are many levels of the underinsured, including those without any coverage; effective policy must address the needs of the total population without shifting costs from one disadvantaged person to another. Kennedy-Kassebaum fails to address the cost issue—the notable worry for those at risk for losing their health insurance. It does nothing to assist the uninsured fetch a decent health policy, and then provides no solution to the important 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 retort to the thunder of greatest pains to the citizens of this country: the cost of medical care. The Bill looks towards the states to perform consumer protections and weakens the regulatory role of the federal government. The majority of the American public is unaware of the cherish footwork alive to with this legislation, and the demographics of the population it is intended to protect. In order to assess the utility of this Bill, it is principal to identify the populations at risk for loosing health insurance coverage and the underinsured.
Kassebaum-Kennedy focuses on a slim share of the uninsured population, and those who would be eligible for COBRA continuation (Consolidated Omnibus Reconciliation Act of 1974). Of the 41 million uninsured Americans, only about 150,000 are expected to encourage from this legislation. The Health Insurance Portability and Accountability Act of 1996 is really nothing more than smoke and mirrors since it fails to address the just announce 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 fervent in treatment studies. Each condition requires individualized treatment that cannot be based upon the simple economic/cost-benefit analysis feeble in the utilization review process by big insurance companies. Clearly, the most effective treatment for one patient may not be the best for another. The time required for utilization review may exhibit 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 befriend about 150,000 people.
Novel studies have found that the majority of the uninsured population simply cannot afford to pay the premiums (Donelan et. al., 1996; Hoffman & Rice, 1996). According to their data, only 1% of the Uninsured population is due to fresh health residence and exclusionary preexisting clauses, yet an overwhelming number of insured respondents reported an inability to receive medical care for chronic conditions. The majority of Americans with chronic illness are covered by some type of insurance, yet they are serene subject to the utilization review process and access problems that sing or delay medically critical 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 reach. If the underwriter did not specifically residence 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 notice spot 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, gigantic insurance companies began including sexual orientation as a high-risk category, by using actuarial sound criteria. Such criteria concluded that jubilant 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 clear individuals to choose 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 befriend as “wildcards” since they allow insurers to mutter 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 impart 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 query 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 gargantuan 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 encourage 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. Wonderful health is care is considerable 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 unpleasant, and infirm, but also restrict the freedom of doctors and other health care providers. Such redistributions may be warranted, but to what level, and to what extent? ” Gutmann & Thompson (Page 178).
Blendon and his colleagues have reported similar findings in public idea polls from 1992 and 1994 (Blendon et. al., 1992; Blendon et. al., 1994). A fresh eye 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 secure health insurance coverage to their preexisting conditions. Among the uninsured, cost is cited as the notable obstacle in obtaining health insurance coverage. Only 1% of the uninsured attributes their lack of coverage to a preexisting condition.
Based upon these democratic principles of distributive justice, consistent understanding polls show 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 advance for. Modern 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 wretchedness about health care in this country, (1992, 1993, 1994, 1995, 1996).
Plot 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 Recount, 1996; US News & World Reports, 1996; Newsweek 1996; Healthline, 1996; The Tennessean, 1996; The Albany Times, 1996; The Nashville Scene, 1996). In their entirety, these case reports relate the human tragedy that lies beneath the web of the very worst of American capitalism: corporate greed.
Identifying Populations At-Risk
A seek by The Lewison Group in 1996 reveals insight into the private individual health insurance market. Clearly, individuals choosing to buy health insurance policies for several hundred dollars each month seek information from their health care needs and expenditures to exceed that amount Regardless of health place, a young healthy 25 year weak who purchases an individual health insurance policy can interrogate to pay well over $300.00 monthly for a health insurance policy with Empire Blue Shield Blue Harmful (based upon 1996 rates, modern rates available from the Current York Position Insurance Department).
Since individual policies are not addressed in the Health Insurance Portability and Accountability Act of 1996 (HIPA), an individual policy with Blue Immoral Blue Shield of Tennessee excludes preexisting conditions for 24 months (enrollment booklet available upon query). The principal markets in need of reform are the adversely selected individual insurance market, and the state’s most vulnerable populations: children; the elderly; the chronically ill; the uninsured; and the underinsured.
For the millions of individuals who have lost their employer based coverage, the cost of private health insurance is prohibitively expensive. Many individuals opt out of the individual market and apply for public assistance when the need arises. Those who have retained their health insurance coverage through their employers are being moved into managed care despite their efforts to maintain 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 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 great evidence that individuals with chronic conditions receive unfriendly care in HMOs.
A four-year longitudinal look of medical outcomes found that the elderly, the abominable, and persons with chronic conditions were in better health when covered by fee-for-service plans compared with a control group covered in HMOs (Ware et. al., 1996). Novel statistics released in Washington, DC by the American Medical Association and the Robert Wood Johnson Foundation revealed the drawl costs of individuals with chronic conditions legend for 75% of verbalize 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 impart inadequate care to this population, then we are looking at 100 million individuals who are potentially facing personal and financial crisis as they are moved into managed care. The public already accounts for the largest payment of sing medical expenditures, which means the millions of dollars being made by for-profit insurance companies are not being circulated into the economy to serve 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 dilapidated to fatten the pockets of CEO’s and majority stockholders (Healthline, 1996).
Based upon a novel recount from the Robert Wood Johnson Foundation, the explain costs for persons with chronic conditions relate 69.4% of national expenditures in personal health care (Robert Wood Johnson Foundation, 1996). Their drawl 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 Perceive 1987, not adjusted for inflation). This population is the most vulnerable to complications in their health and with their source of payment. Stout insurance companies only provide adequate coverage for acute illness (Donelan et al., 1996; Hoffman et. al, 1996).
Medicaid Managed Care
Following Tennessee’s lead, many states have enrolled their medically indigent populations in Medicaid Managed Care Organizations (MCOs). In Daniels v. Wadley, (926 F. Supp. 1305), the court held that TennCare violated the Due Process Clause of the Fourteenth Amendment since such procedures eliminate graceful hearings and independent medical review of disputes. The court found the pattern of routine denials of care by MCOs participating in the states TennCare program to violate the Medicaid Act since it compounded the scrape of institutionalized waiting periods for medical appeals pending independent review by the Medical Review Unit (MRU), (42 U.S.C. § 1396 (a)(8)).
Furthermore, the court ordered federal injunctive protection to participants and beneficiaries because no situation 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 spot 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 rep minute reprieve in the federal courts, so any attempts to believe 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 residence of Arizona commented in 1981, “We play sort of an advocacy role. I consider the public demands something more from physicians than to honest be a blob of bureaucrats, and I deem we have to rob a stand now and then. Our role essentially as patient advocate, is to articulate them, well, objective because the insurance company is not going to pay, that is not the extinguish 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, “gradual every fact found herein is a human face and the reality of being terrible in the richest nation on earth, (936 F. Supp. Dawdle op. At 3).
Perhaps most distressing is the lack of accountability for mismanaged healthcare and faulty 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 necessary human resources as we await decisions to be handed down from status courts. The Supreme Court of the United States has agreed to hear Current York’s quiz for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the dwelling of Unusual York.
When HMOs train 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 examine at tort reform, and put a question to action by the Supreme Court as they advance 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 position 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 peer into the future of TennCare recipients and Medicaid beneficiaries in states around the country. Dating attend to the implementation of the Arizona Health Care Cost Containment System (AHCCCS) in 1981, there are documented cases where “people reportedly died for lack of medical treatment before their eligibility was positive,” (Varley, as cited in Gutman & Thompson, I 996). This leaves me to wonder why the states continue to enroll their most vulnerable populations into a system of managed care that has proven to be a pains.
Perhaps advantageous of comment is that Arizona is the only location to have voted Republican in every election since 1948—certainly provides insight into the conservative morale of the site. Although Arizona was the last dwelling to gather 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 location strategic barriers to access medical treatment and services in Health Maintenance Organizations (HMOs). Pre-certification requirements are strategic barriers incorporated into the “gloomy box” of utilization review that institutionalizes exclusionary waiting periods and routine denials of medically principal treatment. According to federal law, “care and services are to be provided in a manner consistent with the simplicity of administration and the best interests of recipients,” (42 U.S.C. § I 396a (a) (19)). Clearly, such rigid pre-certification requirements that complicate administrative processing and paperwork on the fragment of the enrolled beneficiaries is a violation of United States Code.
Furthermore, using well-known care providers as a mechanism to limit access to specialists not only complicates administrative processing, but limits enrolled beneficiaries choice of health professionals beyond what is available to the general public in the geographic place (42 U.S.C. § 1 396a (a)(30)(A)). Certainly referral procedures do not “yelp that recipients will have their choice of health professionals within the view to the extent possible and appropriate,” (42 U.S.C. § 434.29). Under this provision, it seems that any individual, especially those with chronic health conditions or disabilities should be allowed to determine a famous care provider with more expertise than a nurse practitioner. I will argue that a neurologist is more familiar with the original needs of a patient with Multiple Sclerosis than a nurse practitioner is with microscopic to no knowledge specific to the medical management of degenerative
Under the Medicaid Act of 1966, covered beneficiaries may appeal any utilization review decision which denies care or limits services. The Medicaid Act gives individuals the factual to a graceful hearing in front of an unbiased independent Medical Review Unit (MRU). Furthermore, the Medicaid Act clearly states that medical services for a Medicaid beneficiary may not be terminated until the said beneficiary receives such a hearing
Conclusion
The country as a whole must realize what Mediate Kessler told her courtroom. Her words are certainly words I will not forget—certainly worth being quoted at length:
“This case is about people—children and adults who are sick, unpleasant, and vulnerable—for whom life, in the memorable words of poet Langston Hughes, “ain’t been no crystal stair”. It is written in the dry and bloodless language of “the Iaw”—statistics, acronyms of agencies and bureaucratic entities, Supreme Court case names and quotes, official governmental reports, periodicity tables, etc. But let there be no forgetting the sincere people to whom this bloodless language gives voice: anxious working parents who are too bad to find 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. Unhurried every fact found herein is a human face and the reality of being awful in the richest nation on earth. (Slouch op. At 3). -Judge Gladys Kessler, December 11, 1996.
Patients are routinely being denied medical care– and being forced into a system that incorporates long waiting periods into their physician contracts and handbooks (Green, 1996). The private for-profit insurance industry has single-handedly undermined the solidarity principle of health insurance by using strict underwriting techniques, ridiculous treatment protocols; inconsistent definitions of chronic illness and rigid utilization review procedures unavailable to the consumer; and inconsistent definitions of “chronic illness” and “emergency” (Dallek, 1996). It is an industry which justified using sexual orientation to avoid covering AIDS patients, calling such methods “actuarially sound.” The privatization of a public pleasurable has removed millions of dollars from the healthcare marketplace with “medical loss ratios” of 57% compared to 85% in the dilapidated health insurance market
Although a slim allotment of the general public is unable to bag health insurance coverage due to a preexisting condition, the more considerable assert remains the cost of coverage. The cost of medical care will remain an relate since original legislative efforts evade the express. Current changes in the delivery of health services is of grave inconvenience and different options must be considered in order to obtain more effective ways to provide public and private assistance—MANAGED CARE IS NOT THE Acknowledge!!! FOR-PROFIT HEALTH CARE IS NOT THE Respond! PRIVATIZATION IS NOT THE Retort!
References
Blumstein, J. F. (1996). Health care reform and competing visions of medical care: Antitrust and status 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 Modern 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: Unique York's Ivy League Medical Schools express 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. Recent 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 Modern York Health Reform Act of 1996: Costs of Exclusion. (Unpublished).
Employee Encourage Research Institute. (1992). Sources of health insurance and characteristics of the uninsured. (Deliver 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 small 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 Modern York Times, [On-line]. Available: http://www.nytimes.com
Freudenheim, M. (1996, July 16). Grading becomes stricter on health plans. The Novel York Times. [On-line]. Available: http://www.nytimes.com/sectionS/bUSiness
Health Care Portability and Accountability Act of 1996, Pub. L. No. 104-191 (1996).
Hoffman, C., Rice, D.R., & Sung, H.Y., (1996). Persons with chronic conditions: Their prevalence and costs. Journal of the American Medical Association,276,1473-1479.
Holusha, J. (1996, August18). For doctors togetherness is the current intention of life. The Unique York Times [On-line]. Available: http://www.nytimes.com/Cp960818.htfl1l
Levinson, M. (1996, June 26). As Blue Gross and Blue Shield head into the for-profit sector, it is helping to start the biggest gold hasten since Sutter’s Mill. U.S.New [On-line]. Available: http:/ / www.usnews.com/
Levy, C. J. (1996, July 2). Modern era in Original York hospital-rate belief. 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 gather. States of Health, (December, 1996) Washington, DC: Families USA. Available: http://epn.org/families/safeflet/html
Med-Access Search: Hospital Database. Available: http://medaccess.com/cgi/Hospital_basic.eXe
Metcalf, E. (1996, September 6). Columbia and Cornell understanding alliance—2,800 physicians strong.. Columbia University Spectator, p.1.
Metcalf, E. (1996, September 27). Columbia/Cornell MD’s Ally. Columbia University Represent, p. 1.
Nasr, H. (1996, July 31). Major university hospitals to merge. Columbia University Spectator, pp. 1,8.
Unusual York Health Reform Act of 1996, NY AB 11330.
Pear, R. (1996, May 26). Two trends collide: The rise in depart and of local HMOs. The Fresh York Times [On-line]. Available: http://www.nytimes.com
Perrin, E. C., Newacheck, P., Pless, B. I. Drotar, D., Gortmeaker, Steven, L., Leventhal, I., Perrin, J.M., Stein, R.E., Walker, D.E. Weitzman, M. (1993). Issues keen in the definition and classification of chronic health conditions. Pediatrics, 91(4), 787-793.
Robert Wood Johnson Foundation (December 1995). HealthTracking: HMOs and US health care. Available: http://rwjf.org
Robert Wood Johnson Foundation (February 1995). Market consolidation, antitrust, and public policy in the health care industry: Agenda for future research. Prepared for the council on the economic impact of health care reform (item: HTO1).
Robert Wood Johnson Foundation (December 1995). Health Tracking: HMOs and US health care. Available: http://rwjf.org
Robert Wood Johnson Foundation (February 1995). Market consolidation, antitrust, and public policy in the health care industry: Agenda for future research. Prepared for the council on the economic impact of health care reform (item: HTO1).Robinson, R. (1993). Economic evaluation in health care: Cost-effectiveness analysis. [Education & Debate]. The British Medical Journal,307(6907), 793-795.
Robinson, R. (1993). Economic evaluation in health care: Cost-effectiveness analysis. [Education & Debate]. The British Medical Journal,307(6909), 924-926.
Rosenthal, E. (1996, July 2). Two more hospitals bustle to join forces: Beth Israel-Long Island Jewish Merger to manufacture far-flung empire. The Novel York Times, p. B3.
Rosenthal, E. (1996, July 15). Patients say NY 1-IMOs don’t deal well with complex illnesses. The Novel York Times, p. Al.
Schiff, G. S. (1996, March 16). Managed care issues. Physicians for a National Health Idea. Available: pnhp@aol.com -
Selby, J. V., Fireman, B. H., & Swain, B.E. (1996). Accomplish of a copayment on utilize 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 understanding would raise costs, damage quality. USAToday, [On-line]. Distributed by the National Center for Policy Analysis.
Smolowe, J., Perman, S., & Van Tassel,J. (1996, April 15) A healthy merger? A broad deal makes Aetna the country’s largest health-care company. Time Magazine,14(16).
Spragins, E. (1996, September 24). Special 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, terrible, and chronically if patients treated in HMO and Fee-for-Service systems: Results construct a medical outcomes witness. 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 acquire advantage from failure of health-care disaster. The Unique 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 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 carve financial risk, health insurance companies have restricted enrollment to individuals in abominable 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 first-rate industry. The public sector absorbs the cost of unreimbursed care for chronic care in America (Robert Wood Johnson Foundation, 1996). Based upon these findings, it seems sure that the money being removed from the health care marketplace is fattening the pockets of CEOs and majority stockholders.
Fresh 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 lawful in a civilized society. Few Americans feel salvage 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 shroud only the healthiest individuals ignores the fact that medical care is a social expedient.
Health Insurance Portability Act of 1996
Two years after the Clinton Health Understanding was defeated in Congress, Senator Ted Kennedy and Nancy Kassebaum introduced the Kennedy-Kassebaum Bill in response to growing concerns about selective enrollment procedures broken-down by health insurance companies in the private sector. In the final version of the Bill, insurance companies must limit preexisting condition clauses to twelve months. It has been estimated that this provision of the Bill will benefit an estimated 150,000 Americans find health insurance coverage.
There are many levels of the underinsured, including those without any coverage; effective policy must address the needs of the total population without shifting costs from one disadvantaged person to another. Kennedy-Kassebaum fails to address the cost issue—the well-known danger for those at risk for losing their health insurance. It does nothing to abet the uninsured win a decent health policy, and then provides no solution to the distinguished scream 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 allege of greatest pains 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 treasure 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 well-known to identify the populations at risk for loosing health insurance coverage and the underinsured.
Kassebaum-Kennedy focuses on a slim piece of the uninsured population, and those who would be eligible for COBRA continuation (Consolidated Omnibus Reconciliation Act of 1974). Of the 41 million uninsured Americans, only about 150,000 are expected to back from this legislation. The Health Insurance Portability and Accountability Act of 1996 is really nothing more than smoke and mirrors since it fails to address the good voice at hand—the simple fact that the cost of quality health care in America is becoming a privilege that only the wealthy can afford.
The Cost of Care for Pre-existing Conditions
An individual with high blood pressure may fair require prescription medication. Cancer patients in remission may require chemotherapy, and a person suffering with a degenerative disease may be keen in treatment studies. Each condition requires individualized treatment that cannot be based upon the simple economic/cost-benefit analysis frail in the utilization review process by astronomical insurance companies. Clearly, the most effective treatment for one patient may not be the best for another. The time required for utilization review may reveal additional health risks and complications to a patient suffering from a chronic health condition.
Twelve months without insurance coverage may be financially devastating to some patients, and 63% of Americans have already forgone some type of medical treatment within the last year due to financial constraints. Publicity surrounding Kennedy-Kassebaum has hailed the bill as the “be all and destroy all in progressive legislation, however, in actuality it will only assist about 150,000 people.
Modern 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 spot 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 announce or delay medically vital treatment (Donelan, et. al., Hoffman & Rice, 1996).
Underwriting the Solidarity Principle
Frail 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 dwelling 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 use more services. Insurers began to require health glance place 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, gigantic insurance companies began including sexual orientation as a high-risk category, by using actuarial sound criteria. Such criteria concluded that joyful men were a higher risk for contracting AIDS virus and refused to write policies for anyone believed to be homosexual, (Stone, 1994 as cited in Durant, 1996).
By limiting enrollment to the healthiest members of society, selective enrollment undermines the solidarity principle of health insurance (Davis & Shoen, 1996; Snow, 1996; Stone, 1994). By eliminating those who were suspect of using more services than their healthier counterparts exhaust, insurance companies are able to offer rock bottom prices for young, healthy individuals. By excluding preexisting conditions and requiring positive 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 seize 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 lisp coverage for any illness that “manifested itself before the issuing date of the policy (Stone, 1994 as cited in Durant, 1996).
This statement allows insurers to shriek treatment for benefits and services for the policyholder for undiagnosed illnesses or conditions of which they were unaware. As a result, the insurers began to 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 gargantuan 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 assist analysis and utilization decisions made according to formulas and cost-benefit analysis of treatment protocols.
“The political controversy over the distribution of health care in the United States is an instructive predicament in distributive justice. Gracious health is care is vital for pursuing most other things in life. Yet equal access to health care would require the government to not only redistribute resources from the rich, healthy to the terrible, and infirm, but also restrict the freedom of doctors and other health care providers. Such redistributions may be warranted, but to what level, and to what extent? ” Gutmann & Thompson (Page 178).
Blendon and his colleagues have reported similar findings in public conception 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 distress 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 indispensable obstacle in obtaining health insurance coverage. Only 1% of the uninsured attributes their lack of coverage to a preexisting condition.
Based upon these democratic principles of distributive justice, consistent conception polls show the legitimate role and public desire for government regulation of the health care industry. It has become determined that the federal government must intervene in order to protect natural law rights, the social contract, and the Constitution of the United States. Regulation is needed to protect the individual freedoms, liberty, and the pursuit of “health, happiness, and the American Dream.”
If America is to be the “Land of Opportunity,” then clearly individual health and wellness should be an ideal to come for. Unusual models of distributive justice emphasize public consensus as a legitimate role for government intervention. According to a number of studies by Blendon and his colleagues, the public has reported an overwhelming general anguish about health care in this country, (1992, 1993, 1994, 1995, 1996).
Set 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 Modern York Daily News, 1996; Long Island Newsday, 1996; LA Times, 1996; Picayne Times, 1996; Columbia Spectator, 1996; Columbia University Portray, 1996; US News & World Reports, 1996; Newsweek 1996; Healthline, 1996; The Tennessean, 1996; The Albany Times, 1996; The Nashville Scene, 1996). In their entirety, these case reports portray the human tragedy that lies beneath the web of the very worst of American capitalism: corporate greed.
Identifying Populations At-Risk
A observe by The Lewison Group in 1996 reveals insight into the private individual health insurance market. Clearly, individuals choosing to seize health insurance policies for several hundred dollars each month inquire their health care needs and expenditures to exceed that amount Regardless of health spot, a young healthy 25 year veteran who purchases an individual health insurance policy can quiz to pay well over $300.00 monthly for a health insurance policy with Empire Blue Shield Blue Faulty (based upon 1996 rates, novel rates available from the Fresh York Station Insurance Department).
Since individual policies are not addressed in the Health Insurance Portability and Accountability Act of 1996 (HIPA), an individual policy with Blue Scandalous Blue Shield of Tennessee excludes preexisting conditions for 24 months (enrollment booklet available upon seek information from). The notable 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 squawk or delay care for all services that are not outright medically distinguished. Growing numbers of individuals have suffered irreparable afflict, 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 gargantuan evidence that individuals with chronic conditions receive inferior care in HMOs.
A four-year longitudinal discover 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). Original statistics released in Washington, DC by the American Medical Association and the Robert Wood Johnson Foundation revealed the enlighten costs of individuals with chronic conditions yarn for 75% of drawl 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 boom 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 boom medical expenditures, which means the millions of dollars being made by for-profit insurance companies are not being circulated into the economy to attend 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 unique describe from the Robert Wood Johnson Foundation, the stutter costs for persons with chronic conditions narrate 69.4% of national expenditures in personal health care (Robert Wood Johnson Foundation, 1996). Their verbalize 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 Leer 1987, not adjusted for inflation). This population is the most vulnerable to complications in their health and with their source of payment. Enormous insurance companies only provide adequate coverage for acute illness (Donelan et al., 1996; Hoffman et. al, 1996).
Medicaid Managed Care
Following Tennessee’s lead, many states have enrolled their medically indigent populations in Medicaid Managed Care Organizations (MCOs). In Daniels v. Wadley, (926 F. Supp. 1305), the court held that TennCare violated the Due Process Clause of the Fourteenth Amendment since such procedures eliminate graceful hearings and independent medical review of disputes. The court found the pattern of routine denials of care by MCOs participating in the states TennCare program to violate the Medicaid Act since it compounded the predicament of institutionalized waiting periods for medical appeals pending independent review by the Medical Review Unit (MRU), (42 U.S.C. § 1396 (a)(8)).
Furthermore, the court ordered federal injunctive protection to participants and beneficiaries because no plot law may preempt federal law by depriving individuals of their constitutional rights. The Department of Health and Human Services (HHS) was ordered to revise its utilization review procedures for TennCare recipients in keeping with the Medicaid Act (42 U.S.C. § 1396 (a) (8)) ensuring due process protections for all covered beneficiaries by requiring “services are provided with ‘reasonable promptness,’” (926 F. Supp. 1305).
This case is one of 543 civil suits pending in the region courts for violations of the Medicaid Act (based upon a Lexis-Nexis search performed December 26, 1996). With the passing of H.R. 3507 into public law, (The Welfare Reform Bill) private citizens will secure diminutive reprieve in the federal courts, so any attempts to fill states accountable for violations of federal law will be weak 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 set of Arizona commented in 1981, “We play sort of an advocacy role. I mediate the public demands something more from physicians than to unbiased be a blob of bureaucrats, and I believe we have to grasp a stand now and then. Our role essentially as patient advocate, is to converse them, well, honest because the insurance company is not going to pay, that is not the demolish of all the resources,” (Icenogle, as cited in Gutmann & Thompson, 1996). Never has this statement been needed more than it is today. Unfortunately, as more insurance companies refuse to pay for medical treatment, fewer resources become available for patients in desperate need of financial assistance. As Consider Kessler eloquently stated as she handed down her decision in Salazar v. District of Columbia, No. 93-452, December 11, 1996, “slack every fact found herein is a human face and the reality of being awful in the richest nation on earth, (936 F. Supp. Slouch op. At 3).
Perhaps most distressing is the lack of accountability for mismanaged healthcare and contaminated denials of medically essential 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 location courts. The Supreme Court of the United States has agreed to hear Novel York’s ask for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the set of Current York.
When HMOs deliver care from patients, it is ludicrous to gain individual physicians liable for the utilization decisions made by decentralized corporate review boards. It is time to catch a serious leer at tort reform, and interrogate action by the Supreme Court as they reach the date of Unique 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 region courts. The court must uphold Daniels v. Wadley, and Salazar v. District of Columbia if further lives are to be saved in medicine rather than wasted away in the utilization review procedures. While we wait patiently for District of Columbia circuit court to order injunctive relief, the number of individuals suffering irreparable hurt due to the systematic denial of medical care grows larger each day.
The history of Medicaid Managed Care does not provide a very optimistic gawk into the future of TennCare recipients and Medicaid beneficiaries in states around the country. Dating relieve 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 sure,” (Varley, as cited in Gutman & Thompson, I 996). This leaves me to wonder why the states continue to enroll their most vulnerable populations into a system of managed care that has proven to be a trouble.
Perhaps agreeable of comment is that Arizona is the only station to have voted Republican in every election since 1948—certainly provides insight into the conservative morale of the situation. Although Arizona was the last situation to score the Medicaid cost sharing incentive proposed by the federal government in 1966, it was the first status to force its medically indigent population into managed care in 1981.
Violating Federal Law
Rigid pre-certification requirements and nonspecific utilization review procedures space strategic barriers to access medical treatment and services in Health Maintenance Organizations (HMOs). Pre-certification requirements are strategic barriers incorporated into the “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 section of the enrolled beneficiaries is a violation of United States Code.
Furthermore, using distinguished care providers as a mechanism to limit access to specialists not only complicates administrative processing, but limits enrolled beneficiaries choice of health professionals beyond what is available to the general public in the geographic position (42 U.S.C. § 1 396a (a)(30)(A)). Certainly referral procedures do not “articulate that recipients will have their choice of health professionals within the view 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 significant 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 exiguous to no knowledge specific to the medical management of degenerative
Under the Medicaid Act of 1966, covered beneficiaries may appeal any utilization review decision which denies care or limits services. The Medicaid Act gives individuals the moral to a radiant hearing in front of an unbiased independent Medical Review Unit (MRU). Furthermore, the Medicaid Act clearly states that medical services for a Medicaid beneficiary may not be terminated until the said beneficiary receives such a hearing
Conclusion
The country as a whole must realize what Assume Kessler told her courtroom. Her words are certainly words I will not forget—certainly worth being quoted at length:
“This case is about people—children and adults who are sick, 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 proper people to whom this bloodless language gives voice: anxious working parents who are too unpleasant to accept 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. Slow every fact found herein is a human face and the reality of being unpleasant 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 kindly has removed millions of dollars from the healthcare marketplace with “medical loss ratios” of 57% compared to 85% in the feeble health insurance market
Although a slim piece of the general public is unable to find health insurance coverage due to a preexisting condition, the more famous deny remains the cost of coverage. The cost of medical care will remain an jabber since current legislative efforts evade the content. Original changes in the delivery of health services is of grave exertion 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 Acknowledge!
References
Blumstein, J. F. (1996). Health care reform and competing visions of medical care: Antitrust and plot 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 Current York Times [On-line. Available: http://www.ny€mes~com/
College of Physicians and Surgeons at Columbia-Presbyterian Medical Center Office of Public Relations. (1996, July 25) Press Release: Recent York's Ivy League Medical Schools vow first of its kind affiance.
Clymer, A. (1996, August 1). Accord reached on expanding worker's health benefits. The Novel York Times [On-line] Available: http://www.nytimes.com/yr/mo/day/pOlitic5/healthbffl.htmI
Consumer Reports. (1996, May 31). Children and health care.
Davis, K., & Shoen, (1996, March). Health services research and the changing health care system. Modern York: The Commonwealth Fund. Available: http://www.cmwf.org
Donelan, K., Blendon, R. J. Hill, C.A., Hoffman, C., Rowland, D., Frankel, M., Altman, D. (1996). Whatever happened to the health insurance crisis in the United States? Journal of the American Medical Association,276(16), 1346-1350.
Durant, E.D. (1996). The 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. (Teach 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 small 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 Original 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 fresh scheme of life. The Current York Times [On-line]. Available: http://www.nytimes.com/Cp960818.htfl1l
Levinson, M. (1996, June 26). As Blue Infamous and Blue Shield head into the for-profit sector, it is helping to open the biggest gold hasten since Sutter’s Mill. U.S.New [On-line]. Available: http:/ / www.usnews.com/
Levy, C. J. (1996, July 2). Fresh era in Fresh York hospital-rate idea. The Unusual York Times, pp. Al.
Malpractice law evolves under managed care. Paper presented at the conference, Emerging Liability Issues in Managed Care, sponsored by the Robert Wood Johnson Foundation’s Improving Malpractice Prevention and Compensation Systems (IMPACS) program, October, 1995.
Market competition and the health care safety rep. States of Health, (December, 1996) Washington, DC: Families USA. Available: http://epn.org/families/safeflet/html
Med-Access Search: Hospital Database. Available: http://medaccess.com/cgi/Hospital_basic.eXe
Metcalf, E. (1996, September 6). Columbia and Cornell understanding alliance—2,800 physicians strong.. Columbia University Spectator, p.1.
Metcalf, E. (1996, September 27). Columbia/Cornell MD’s Ally. Columbia University Report, 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 fade and of local HMOs. The Recent York Times [On-line]. Available: http://www.nytimes.com
Perrin, E. C., Newacheck, P., Pless, B. I. Drotar, D., Gortmeaker, Steven, L., Leventhal, I., Perrin, J.M., Stein, R.E., Walker, D.E. Weitzman, M. (1993). Issues eager in the definition and classification of chronic health conditions. Pediatrics, 91(4), 787-793.
Robert Wood Johnson Foundation (December 1995). HealthTracking: HMOs and US health care. Available: http://rwjf.org
Robert Wood Johnson Foundation (February 1995). Market consolidation, antitrust, and public policy in the health care industry: Agenda for future research. Prepared for the council on the economic impact of health care reform (item: HTO1).
Robert Wood Johnson Foundation (December 1995). Health Tracking: HMOs and US health care. Available: http://rwjf.org
Robert Wood Johnson Foundation (February 1995). Market consolidation, antitrust, and public policy in the health care industry: Agenda for future research. Prepared for the council on the economic impact of health care reform (item: HTO1).Robinson, R. (1993). Economic evaluation in health care: Cost-effectiveness analysis. [Education & Debate]. The British Medical Journal,307(6907), 793-795.
Robinson, R. (1993). Economic evaluation in health care: Cost-effectiveness analysis. [Education & Debate]. The British Medical Journal,307(6909), 924-926.
Rosenthal, E. (1996, July 2). Two more hospitals race to join forces: Beth Israel-Long Island Jewish Merger to develop far-flung empire. The Original York Times, p. B3.
Rosenthal, E. (1996, July 15). Patients say NY 1-IMOs don’t deal well with complex illnesses. The Original York Times, p. Al.
Schiff, G. S. (1996, March 16). Managed care issues. Physicians for a National Health Understanding. Available: pnhp@aol.com -
Selby, J. V., Fireman, B. H., & Swain, B.E. (1996). Attain of a copayment on exercise 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 conception would raise costs, afflict 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 enormous deal makes Aetna the country’s largest health-care company. Time Magazine,14(16).
Spragins, E. (1996, September 24). Special Recount America’s best 1-IMOs: Rating the top managed care companies. Newsweek, pp.58-63.
Stone, D. A. (Monroe, J. A. & Beilcin, C. S. eds. 1994). The struggle for the soul of health insurance. The Politics of Health Care Reform,27-56.
Taylor, H. (1996, July 16). Health care capitalism remakes a city’s health system. The Albany Times [On-line]
Toim L (1996 July 31) Local 2110 loses its benefits Columbia University Spectator, pp 1-5
Van Duzer, K., & Nasr, H. (1996,July 31). Nurses reject final hospital’s offer, strike possible. Columbia University Spectator, pp. 1,8.
Ware, J.E., Bayliss, M.S., Rogers,W.H., Kosinski, M., Tarlov, A.R. (1996). Differences in 4-year health outcomes for elderly, awful, and chronically if patients treated in HMO and Fee-for-Service systems: Results gain a medical outcomes survey. 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 get advantage from failure of health-care concern. The Unique York Times [On-line]. Available: http://www.nytimes.cOm/web/dOcsroot/library/Politics/0730editon.html
